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A  HANDBOOK 


VACCINATION. 


EDWARD   C.  ^SEATON,  M.D., 

MEDICAL  INSPECTOR  TO  THE  PRIVY  CODKCIL. 


PHILADELPHIA: 

J.  B.  LIPPINCOTT  &  00. 

1868. 


pfl 


[\ 


PREFACE. 


In  planning  this  book  I  had  two  purposes  mainly  in 
view — intimately  associated  with  each  other. 

The  first  of  these  was  to  provide  a  text-book  on 
the  science  and  practice  of  Vaccination  for  the  use  of 
my  younger  professional  brethren,  and  of  medical  stu- 
dents. 

In  the  constant  intercourse  which,  from  the  nature 
of  my  office,  I  have  for  many  years  past  had  in  refer- 
ence to  this  subject  with  medical  friends  who  are 
interested  in  it,  and  of  course  especially  with  that 
large  part  of  the  profession  who  are  engaged  as  Pub- 
lic Yaccinators,  I  have  been  repeatedly  asked  for  advice 
on  various  points  connected  with  the  practice  and  use 
of  Vaccination,  and  have  many  times  heard  the  wish 
expressed  that  there  existed  some  book  in  which  the 
whole  subject  could  be  found  fully  treated. 

It  is  a  curious  fact  that  since  the  publication,  in 
1809,  of  the  enlarged  edition  of  Bryce's  "Practical 

(Hi) 


iv  PREFACE, 

Observations  on  the  Inoculation  of  the  Cow-pox," 
there  has  been  no  separate  work  published  in  the 
United  Kingdom  which  treats  completely  of  Vaccina- 
tion. To  the  different  branches  of  the  subject  contri- 
butions of  the  utmost  value  have  been  made — to  the 
natural  history  of  Cow-pox,  to  its  affinities  with  dis- 
eases in  other  animals  and  with  Small-pox  in  man,  to 
the  practice  of  Vaccination,  to  the  determination  of  the 
hygienic  value  of  that  practice  and  the  circumstances 
by  which  this  is  affected :  but  no  book  giving  a  full  but 
concise  view  of  the  whole  subject.  And  although,  of 
course,  a  general  view  of  Vaccination  has  been  pre- 
sented in  systematic  works  on  medicine,  in  medical 
dictionaries,  cyclopaedias,  etc.,  it  was  impossible  that 
so  large  a  subject  could  be  considered  with  the  re- 
quisite fullness  in  the  necessarily  limited  space  that 
in  such  works  could  be  allotted  to  it. 

I  was  moreover  particularly  induced  to  attempt  this 
work  from  noticing  that  by  many  practitioners  the 
operation  of  Vaccination  was  not,  as  it  appeared  to 
me,  regarded  at  its  real  value.  Seemingly  so  simple 
in  itself,  many  of  the  niceties  and  cautions  which  so 
greatly  influence  success,  and  the  value  of  which  is  so 
well  known  to  the  practiced  vaccinator,  have  been 


PREFACE.  v 

unheeded  in  general  practice,  and  I  could  not  but  deem 
it  of  very  great  importance  that  attention  should  be 
called,  or  recalled,  to  them.  I  had  this  object  espe- 
cially in  view  in  the  practical  section  of  an  article  on 
Vaccination  which  I  contributed  to  Reynolds's  "  Sys- 
tem of  Medicine:"  and  in  the  larger  treatment  of  this 
part  of  the  subject  in  the  present  work,  I  have  taken 
great  pains  in  the  same  direction. 

My  other  purpose  had  reference  to  such  assistance 
as  I  thought  I  might  be  able  to  give  to  those  engaged 
in  the  administration  of  the  system  of  Public  Vaccina- 
tion established  in  England.  In  this  part  of  the  book 
I  have  had  to  treat  of  matters  partly  professional,  and 
partly  administrative.  The  administrative  sections  of 
the  work  might  at  first  sight  appear  to  concern  only  a 
portion — itself,  however,  not  an  inconsiderable  portion 
— of  the  medical  practitioners  of  the  kingdom,  yet  it  is 
clear  that  the  principles  on  which  a  public  system  of 
Vaccination  should  be  based  are  of  interest  and  import- 
ance to  the  whole  profession.  There  are,  besides,  very 
many  others  than  professional  men  to  whom  a  right 
understanding  of  these  principles  is  indispensable,  and 
notably  to  the  Guardians  of  Unions  on  whom  it  de- 


vi  PREFACE. 

volves  to  make  the  local  arrangements.  It  is  always 
a  difficult  matter  to  present  a  technical  subject  so  as  to 
make  it  thoroughly  intelligible  to  those  who  have  had 
no  professional  training;  but  the  principles  are  broad 
principles,  and  I  trust  I  may  have  explained  them 
with  sufficient  clearness. 

Each  division  of  the  United  Kingdom  has  its  own 
Vaccination  law.  It  is  the  system  in  use  in  England 
to  which  this  book  refers :  but  England  in  legal  phrase- 
ology includes  always  the  principality  of  Wales,  and 
throughout  the  book,  whenever  I  have  mentioned 
"England,"  I  must  be  taken  to  have  said  "England 
and  Wales." 


CONTENTS. 


CHAPTEK  I. 

nun 

Of  the  Natural  Cow-pox 9 

CHAPTER  II. 
Of  the  Horse-pox 33 

CHAPTER  III. 

Of  Pocks  in  other  Animals  which  have  been  considered 
analogous  to  Cow-pox  and  Horse-pox  ...      44 

CHAPTER  IV. 

Of  the  Relation  of  Cow-pox  and  Horse-pox  to  Human 
Variola 56 

CHAPTER  V. 

Of  Vaccinia,  or  Cow-pox,  in  the  Human  Subject   .         .       80 

CHAPTER  VI. 
Of  Vaccinating 115 

CHAPTER  VII. 

Of  Arrangements  for  the  Performance  of  Vaccination 
and  the  Maintenance  of  Lymph-supply      .        .        .     140 

(vii) 


viii  CONTENTS. 

CHAPTEE  VIII. 

PAGE 

Of  the  Conveyance  and  Storage  of  Lymph     .        .        .158 

CHAPTEE  IX. 

Of  Skill  and  Success  in  Vaccinating,  and  of  Insuscepti- 
bility to  Vaccination 179 

CHAPTEE  X. 

Of  alleged  Degeneration  of  Lymph,  and  of  Eecurrence 
to  the  Cow 199 

CHAPTEE  XI. 

Of  the  Protection  which  Vaccination  affords  against 
Small-pox 211 

CHAPTEE  XII. 
Of  Eevaccination 299 

CHAPTEE  XIII. 

Of  Stamping-out  Local  Outbreaks  of  Small-pox     .        .     314 

CHAPTEE  XIV. 

Of  the  Objections  to  Vaccination,  and  the  alleged  Dan- 
gers of  the  Practice ,    .        .     328 


Handbook  of  Vaccination. 


CHAPTER    I. 


OF   THE    NATURAL   COW-POX. 


1.  Cow-pox  in  the  Cow. — Vaccinia,  or  the  Cow- 
pox — the  Variolae  Vaccinae  of  Jenner — is  never  met 
with  in  the  human  subject  but  as  the  result  of  inocula- 
tion. It  is  only  in  the  cow  and  in  the  horse  that  we 
have  any  certain  or  definite  knowledge  of  it  as  a  natural 
disease,  though  it  probably  does  occur  as  such  in  some 
other  animals. 

2.  General  Description.  —  The  natural  history  of 
Vaccinia  in  the  cow  has  been  studied  more  or  less  by 
various  observers,  but  by  none  so  accurately  or  so 
comprehensively  as  by  our  distinguished  countryman, 
Robert  Ceely;  and  it  is  his  account  of  the  disease 
which  I  shall  chiefly  follow.  It  is  a  specific  eruptive 
disease,  of  the  vesicular  order,  the  eruption  not  being 
general  over  the  body,  but  limited  (except  as  the  result 
of  accidental  or  casual  inoculation)  to  the  udder  and 
teats.  It  is  met  with  from  time  to  time,  either  sporad- 
ically, or  (less  commonly)  as  an  epizootic.  It  particu- 
larly attacks  milch  cows:    indeed,  as  a  spontaneous 

2  (9) 


10  HANDBOOK  OF   VACCINATION. 

disease,  it  occurs  almost  if  not  quite  exclusively  when 
the  animal  is  in  that  condition.*  Young  cows  and 
milch  heifers  appear  to  be  more  subject  to  it  than 
older  cows.  In  its  earliest  stages  it  is  attended  with 
so  little  general  or  obvious  local  disturbance  that,  in 
the  animals  first  attacked  in  a  dairy,  these  stages  sel- 
dom come  under  skilled  observation ;  and  as  the  fluid 
of  the  vesicles  is  very  infective,  and  the  disease  is  thus 
readily  conveyed  from  animal  to  animal  by  the  milkers, 
it  is  difficult  to  distinguish,  in  animals  subsequently 
attacked,  between  those  exhibiting  the  natural  disease 
and  those  who  have  been  infected  casually  by  inocula- 
tion. The  distinction,  indeed,  is  not  of  any  practical 
moment :  the  course  of  the  affection  is  in  either  case 
essentially  the  same,  and  such  difference  as  is  believed 
to  exist  has  reference  only  to  the  duration,  longer  or 
shorter  by  a  day  or  so,  of  certain  stages  in  the  one 

*  "  It  is  considered  that  the  disease  is  peculiar  to  the  milch 
cow — that  it  occurs  primarily  while  the  animal  is  in  that  con- 
dition— and  that  it  is  casually  propagated  to  others  hy  the 
hands  of  the  milkers.  But  considering  the  general  mildness 
of  the  disease,  the  fact  of  its  being  at  times  in  some  individ- 
uals entirely  overlooked,  and  that  its  topical  severity  depends 
almost  wholly  on  the  rude  traetions  of  the  milkers,  it  would 
perhaps  be  going  too  far  to  assert  its  invariable  and  exclusive 
origin  under  the  circumstances  just  mentioned ;  yet  I  have 
frequently  witnessed  the  fact  that  sturks,  dry  heifers,  dry 
cows,  and  milch  cows  milked  by  other  hands,  grazing  in  tRe 
same  pastures,  feeding  in  the  same  sheds  and  in  contiguous 
stalls,  remain  exempt  from  the  disease."  (Ceely,  in  Trans. 
Provincial  Medical  and  Surgical  Assoc,  vol.  viii.  p.  299.) 
Ceely  subsequently  saw  what  appeared  to  be  a  case  of  primary 
infection  in  a  sturk.  (See  Trans.  Prov.  Med.  and  Surg. 
Assoc,  vol.  x.  p.  223.) 


OF  THE  NATURAL    COW-POX.  \\ 

case  than  in  the  other.  These  differences,  so  far  as 
they  have  been  ascertained,  will  be  pointed  out  in  the 
following  description,  which,  otherwise,  may  be  taken 
to  represent  both  the  natural  disease  and  the  disease 
as  conveyed  by  casual  inoculation. 

3.  Course  of  Local  Phenomena. — There  is  first  a 
period  of  incubation ;  but,  from  the  extreme  slightness 
of  the  earliest  symptoms,  it  is  very  difficult  to  say  how 
soon  after  infection  has  been  received  these  may  mani- 
fest themselves.  In  the  natural  disease  the  incubative 
period  is  probably  three  or  four  days,  though  Ceely 
thinks  there  is  reason  to  believe  it  may  in  some  cases 
be  prolonged  to  from  five  to  eight  days.  The  earliest 
symptoms  noted  are  heat,  swelling,  and  tenderness  of 
the  udder,  soon  followed  by  irregularity  of  surface,  and 
development  of  hard  papules  about  the  size  of  a  vetch 
or  pea,  especially  on  that  part  of  the  udder  which  ad- 
joins the  bases  of  the  teats,  and  on  the  bases  of  the 
teats  themselves.  There  is  not  generally,  at  this  stage, 
any  loss  of  appetite,  manifestation  of  fever,  or  other 
sign  of  constitutional  disturbance.  In  the  casual  dis- 
ease, or  that  which  arises  from  infection  by  the  unin- 
tentional inoculations  of  the  milkers,  it  is  very  rare  for 
any  indications  of  contagion  to  manifest  themselves  till 
the  sixth  or  seventh,  sometimes  they  do  not  appear  till 
the  eighth  or  ninth,  day  after  undoubted  exposure ;  but 
in  thin-skinned  animals,  with  cracks  and  chaps  in  the 
teats,  small  red  tender  papules  may  often  be  found  by 
vigilant  observation  as  early  as  the  fifth  day.  The 
papules  increase  in  size  as  the  disease  goes  on,  and  in 
three  or  four  days  from  their  first  appearance  many  of 
them  will  be  found  to  have  acquired  a  distinct  vesicular 
character,  with  more  or  less   of  central  depression. 


12  HANDBOOK  OF   VACCINATION. 

The  first  change  from  papule  to  vesicle  is  indicated  by 
the  appearance  of  a  dull  or  dusky  yellowish  point  at 
the  apex  of  the  pimple ;  the  circumference  then  increases 
in  substance  and  extent,  and  the  center  becomes  wider 
and  deeper,  till  at  last  the  flattened  vesicle  with  de- 
pressed center  is  formed.  As  with  the  papules,  so 
with  the  vesicles,  there  is  gradual  increase  of  size,  un- 
til in  three  or  four  days  more  their  full  development  is 
attained.  The  number,  size,  shape,  and  color  of  the 
vesicles  differ  much  in  different  animals,  as  well  as  in 
different  parts  of  the  same  animal.  There  may  be  only 
one  or  two  of  them,  but  much  more  frequently  there 
are  ten,  twenty,  or  more  :*  they  are  most  common  on 
the  base,  neck,  and  body  of  the  teats,  often  exist  on  the 
udder,  occasionally  at  the  apex  of  the  teats.  Their  size 
varies  from  that  of  a  large  pin's  headf  to  that  of  a  six- 
pence, or  bigger,  but  is  most  ordinarily  that  of  a  vetch, 
pea,  or  horse-bean ;  in  general,  the  more  numerous  the 
vesicles  are  the  smaller  they  are.  Their  shape  is  de- 
termined chiefly  by  their  position :  around  the  base  and 


*  The  amount  of  eruption,  and  consequently  the  severity  of 
the  disease,  depends  greatly  on  the  state  of  the  teats  and 
udder.  With  a  short,  compact,  hairy  udder,  and  thick, 
smooth,  tense,  unchapped  or  scarcely  cracked  teats,  the  affec- 
tion is  often  very  mild,  and  sometimes  there  is  only  a  single 
vesicle.  An  animal  with  a  voluminous,  flabby,  naked,  pendu- 
lous udder,  and  loose  long  teats,  the  skin  of  which  is  thin,  fis- 
sured, rough,  and  unequal,  scarcely  ever  escapes  a  copious 
eruption.     (Ceely,  Transact,  etc.,  vol.  viii.  p.  303.) 

f  These  very  small  vesicles  are  no  doubt  of  later  origin 
than  the  others,  the  results  of  accidental  auto-inoculation  from 
pressure  when  the  animal  lies  down,  or  of  inoculations  by  the 
milkers. 


OF  THE  NATURAL    COW-POX.  13 

neck  of  the  teats,  they  are  almost  invariably  circular ;  on 
the  body  of  the  teats,  generally  oval;  but  oval  vesicles 
may  be  seen  also  on  the  udder,  and  the  vesicles  on  the 
teats  are  often  interfluent.  The  color  of  the  vesicles  varies 
according  to  the  period  of  their  progress,  and  according 
to  the  color  and  texture  of  the  animal's  skin ;  but  they 
have  always  a  metallic  glistening  aspect.  By  the  time 
that  the  vesicle  is  completely  formed,  it  is  frequently 
seven  or  eight  lines  wide  ;  has  a  solid,  uniform,  tense, 
and  shining  margin,  a  glistening  white,  pinky,  or  sil- 
very hue,  and  a  bluish  or  slate-colored  center ;  it  con- 
tains a  clear  viscid  lymph,  which,  however,  is  even  at 
this  period  generally  in  small  quantity  and  often  diffi- 
cult to  obtain  ;  and  around  its  base  there  is  a  narrow, 
pale  rose,  or  light-damask  areola,  not  more  than  a  line 
or  two  wide,  and  sometimes  scarcely  so  much,  though 
subsequently  extending,  with  circumscribed  induration 
of  the  adjacent  skin  and  subjacent  connective  tissue. 
The  color  of  the  areola,  like  that  of  the  vesicles,  is 
greatly  influenced  by  the  hue  and  texture  of  the  skin ; 
and  in  some  skins — as  in  dark,  thick  ones — the  areola 
is  scarcely  to  be  seen,  or  is  entirely  absent;  but  the 
induration  is  always  palpable.  Between  the  tenth  and 
eleventh  days  the  disease  has  generally  reached  its 
acme ;  the  areola  has  extended,  though  seldom  to  more 
than  a  width  of  from  four  to  five  lines,  and  there  is 
deep  induration  of  the  underlying  integument.  The 
vesicles,  such  as  have  not  been  broken,  are  at  their 
fullest  development;  lymph,  which  two  days  before 
was  hard  to  get  from  them,  is  now  so  copious  that  it 
raises  the  cuticle,  destroying  the  central  depression  and 
forming  a  globular  or  conoidal  vesicle,  or  it  bursts  the 
2* 


14  HANDBOOK  OF   VACCINATION. 

cuticle  and  flows  freely  out;*  it  has  already  acquired, 
or  soon  acquires,  a  pale  straw-colored  or  light  amber 
hue,  and  speedily  becomes  more  serous,  turbid,  and 
opaque.  While  this  is  taking  place  in  some  vesicles, 
in  others  the  process  of  incrustation  will  already  have 
begun  at  the  center,  and  in  others  it  may  even  have 
extended  to  the  circumference. f  On  and  after  the 
twelfth  day,  nearly  all  is  passive ;  the  incrustation- 
process  continues  steadily  to  advance,  and  by  the  thir- 
teenth or  fourteenth  day  the  crusts  have  usually  ac- 
quired their  greatest  magnitude,  are  of  a  brownish- 
black  color,  adhering  more  or  less  tenaciously  to  the 
epidermis  or  skin  beneath,  the  marginal  induration  and 
intumescence  at  the  same  time  subsiding.     The  crusts 

*  This  acumination  of  the  vesicle,  however,  is  not  uniform 
either  as  to  its  presence  or  as  to  its  time  of  appearance.  It 
may  take  place  at  an  earlier  or  later  period,  or  it  may  not 
occur  at  all. 

f  Unequivocal  cases  of  the  natural  disease — the  first  cases 
in  a  dairy — seldom  or  never  come  under  the  notice  of  any  one 
competent  to  judge  of  the  nature  of  the  ailment,  until  it  has 
arrived  at  this  stage,  when  almost  invariably  considerable 
disturbance  of  the  vesicles  has  taken  place  from  traction  in 
milking.  Many  broken  vesications  will  then  be  found,  having 
evidently  a  central  depression  with  marginal  induration ;  if 
any  be  found  unbroken,  they  will  be  usually  acuminated,  and 
full  of  amber-colored  fluid  more  or  less  viscid,  but  on  being 
punctured  will  collapse,  and  at  once  indicate  the  same  kind  of 
central  and  marginal  character.  With  these  there  will  be 
mingled  smaller  vesicles,  evidently  of  later  date,  either  acumi- 
nated or  depressed,  and  crusts  circular  or  ovoid  on  the  udder, 
circular,  oval,  or  irregular  on  the  teats;  the  appearance  of  the 
disease  at  different  stages,  or  at  least  the  formation  of  a  few 
vesicles  at  different  periods,  being  very  evident.  (Ceely, 
Transact,  etc.,  vol.  viii.p.  306.) 


OF  THE  NATURAL   COW-POX.  15 

after  this  go  on  drying  and  shrinking,  and  they  fall  off 
usually  from  the  twentieth  to  the  twenty-third  day,  by 
which  time  the  induration  has  nearly,  but  seldom 
wholly,  disappeared.  The  cicatrices  left  after  the  fall- 
ing of  the  crusts  are  shallow,  smooth,  oval  or  circular, 
and  of  pale-rose,  white,  or  whitish  color,  according  to 
the  contrast  of  the  surrounding  pigment.  The  vesicles 
on  the.  teats  are  attended  generally  with  less  areola 
and  less  induration  of  circumference  than  those  on  the 
udders,  but  in  other  respects,  in  so  far  as  they  are  un- 
disturbed and  out  of  the  way  of  the  milkers,  they  ex- 
hibit exactly  the  same  phenomena  and  undergo  pre- 
cisely similar  changes. 

4.  The  Local  Affection  as  disturbed  by  handling. — 
Such  is  the  course  of  the  undisturbed  eruption  ;  but 
from  the  tractions  of  the  milkers  it  seldom  happens 
that  the  vesicles,  where  they  are  most  numerous,  viz., 
on  the  base,  neck,  and  bodies  of  the  teats,  escape  dis- 
turbance. By  the  eighth  or  ninth  day,  when  the  un- 
injured vesicles  are  the  most  perfect,  injured  ones  will 
be  found  exuding  lymph  from  their  centers,  the  cuticle 
being  loose  or  partially  detached.  Haw  surfaces  and 
brown  or  black  crusts  will  be  intermingled,  and  here 
and  there  will  be  seen  a  conoidal  vesicle,  often  with 
slightly  depressed  apex,  distended  with  pellucid  lymph. 
Two  or  three  days  later,  the  appearances  on  the  teats 
will  exhibit  crusts  large,  black,  and  solid,  often  more 
than  an  inch  or  two  long,  some  firmly  adherent  to  a 
raw  and  elevated  base,  others  partially  detached  from 
a  raw,  red,  and  bleeding  surface  ;  many  florid  red  ulctr- 
ated  surfaces  secreting  pus  and  exuding  blood  ;  the 
teats  excessively  tender,  hot,  and  swollen,  not  unfiv- 
quently  one  or  more  forming  a  tumid  mass  of  black 


16  HANDBOOK  OF   VACCINATION. 

crusts  and  naked  red  sores,  the  discharge  from  which 
imparts  to  the  finger  an  odor  very  closely  resembling 
that  of  the  last  stage  of  smallpox.  In  some  animals 
this  state  will  continue  for  a  week  or  two,  but  in  others 
the  process  of  healing  will  go  regularly  on,  crusts 
being  continually  formed  and  renewed,  till  at  last  they 
fall  off,  and  leave  cicatrices  generally  regular,  smooth, 
circular  or  oval,  but  occasionally  deep  and  irregular.* 
5.  Duration  of  the  various  stages  of  Cow-pox. — 
Thus  the  normal  course  of  the  disease  occupies  from 
twenty  to  twenty-three  days,  which  may  be  divided 
into  four  stages,  viz.:  "  a,"  about  four  days  of  early 
symptoms,  during  which  papulation  takes  place  ;  "  b," 
six  or  seven  days  to  the  full  development  and  perfect 
maturation  of  the  vesicle;  "c,"  five  or  six  of  decline 
of  the  vesicle  and  formation  of  the  crusts;  and  "  d," 
five  or  six  more  from  the  completion  of  incrustation  to 
the  spontaneous  separation  of  the  crusts.  Stages  "a" 
and  "b"  are  often  materially  abridged  in  the  natural 
disease ;  while  in  the  casual  disease  "  a"  is  sometimes 
prolonged,  "b"  being  proportionally  abridged,  or  "a" 
is  prolonged,  "b"  and  all  subsequent  stages  occupying 
the  normal  duration.  These  variations,  however,  in 
the  early  stages  of  the  disease  are  often  more  supposed 
than  real,  the  earliest  symptoms  being  so  extremely 
slight  in  many  cases  that  they  are  overlookd.  Both 
in  the  natural  and  casual  cow-pox,  "c"  is  sometimes 
prolonged,  often  abridged.  The  whole  of  the  cow-pox 
eruption  is  not  by  any  means  always  simultaneously 
developed.  Papules,  depressed  vesicles,  acuminated 
or  globular  vesicles,  and  vesicles  more  or  less  desic- 

*  See  Ceely,  Transact,  etc.,  vol.  viii.  pp.  308-312. 


OF  THE  NATURAL    COW-POX.  n 

cated,  varying  in  size  from  a  pin's  head  to  a  diameter 
of  eight  or  ten  lines,  may  be  seen  on  the  same  subject 
at  the  same  time ;  but  all,  whatever  their  date  of  ap- 
pearance, terminating  together.  No  doubt  these  ap- 
parent anomalies  are  due  either  to  self-vaccination  of 
the  cow  from  pressure,  as  in  the  act  of  lying  down, 
or,  still  more  frequently,  to  the  manipulations  of  the 
milkers. 

6.  Structure  of  the  Cow-pox  Vesicle. — If  we  examine 
the  anatomical  structure  of  the  cow-pox  vesicle,  when 
completely  formed,  we  find  it  to  consist  of  a  number  of 
cells,  which  appear  to  be  arranged  in  two  concentric 
rows,  and  are  separated  from  each  other  by  whitish 
radiating  partitions  united  at  their  converging  extremi- 
ties by  a  central  membranous  band.  In  these  cells  is 
secreted  and  contained  a  clear  viscid  lymph.  "  The 
dusky  central  spot — which  marked  the  first  change  of 
the  pimple  into  the  vesicle,  and  which  has  now  become 
darker  and  more  distinct — seems  to  be  caused  by  a 
greater  or  less  degree  of  separation  of  the  epidermis, 
stretched  over  a  crypt-like  recess,  which  contains  a 
small  quantity  of  semi-concrete  lymph-like  matter,  oc- 
casionally a  turbid  opaque  fluid."  This  cellular  con- 
formation of  the  vesicle  is  essential  and  diagnostic.  It 
is  by  the  bursting  and  breaking  up  of  the  cells  and 
their  connecting  band,  as  the  lymph  becomes  more 
abundant  and  less  viscid,  and  by  separation  of  the 
epidermis  from  its  attachment  to  the  subjacent  adven- 
titious membranae,  that  the  vesicle  in  its  further  pro- 
gress loses  its  distinctive  central  depression,  and  ac- 
quires the  acuminate  or  conoidal  form  which  has  been 
described.* 

*  See  Ceely,  Transact,  etc.,  vol.  viii.  p.  317. 


18  HANDBOOK  OF   VACCINATION. 

7.  Constitutional  Symptoms. — The  local  symptoms 
of  cow-pox  in  the  cow  are  seldom  accompanied  by  any 
material  constitutional  disturbance ;  in  the  great  major- 
ity of  animals,  feeding  and  grazing  go  on  apparently 
as  usual.  The  secretion  of  milk  is  sometimes  dimin- 
ished ;  and,  in  most  instances,  the  amount  artificially 
obtained  is  greatly  lessened  from  the  trouble  and  diffi- 
culty of  milking.  In  some  cases,  the  cow  exhibits  in 
the  course  of  vaccinia  a  peculiar  vesicular  eruption 
very  like  vesicular  varicella.  It  occurs  generally  about 
the  ninth  or  tenth  day,  commencing  with  erythemato- 
papular  elevations,  which  in  twenty-four  hours  have 
become  vesicles  full  of  pellucid  serous  fluid.  Next  day 
this  fluid  is  straw-colored,  and  it  becomes  speedily 
turbid,  the  cuticle  collapses  or  bursts,  turns  yellowish- 
brown,  and  before  the  fifth  day  from  their  origin  the 
vesicles  desiccate  with  brown  or  black,  thin,  flimsy 
crusts,  which  soon  fall  off.* 

8.  Spurious  Pocks,  etc. — The  description  of  cow- 
pox  above  given  will,  it  is  trusted,  enable  the  practi- 
tioner always  to  recognize  the  natural  disease  in  the 
cow,  when  it  is  presented  to  his  observation  ;  but  the 
cow  is  liable  to  other  diseases,  which  more  or  less 
resemble  cow-pox,  and  from  which  it  is  important  to 
distinguish  it — a  distinction  all  the  more  necessary  that 
some  of  these  diseases  may,  and  in  fact  not  uncom- 
monly do,  either  coexist  with  it  or  immediately  pre- 
cede or  follow  it.  Besides  certain  cutaneous,  sub- 
cutaneous, and  follicular  inflammations  and  suppura- 
tions on  the  udders  and  teats,  which  are  liable  to  affect 
occasionally  the  hands  of  the  milkers,  warty  growths 

*  See  Ceely,  Transact,  etc.,  p.  329. 


OF  THE  NATURAL   COW-POX.  \% 

and  even  warty  vesicles  (that  can  scarcely,  however, 
be  confounded  with  vaccinia),  and  eczema,  or  other 
superficial  vesicular  eruptions,  Ceely  particularly  no- 
tices three  kinds  of  spurious  pock :  "  Tlie  Yellow 
Pock,  a  pustular  eruption  resembling  ecthyma  on  the 
teats  and  udders,  succeeded  by  thin,  dirty-brown,  or 
black  irregular  crusts ;  the  Bluish  or  Black  Pock, 
bluish  or  black  or  livid  vesications  on  the  teats  and 
udders,  followed  by  thin  dirty-brown,  or  black  irregular 
crusts,  and  some  degree  of  impetigo  on  the  interstices, 
near  the  bases  of  the  teats ;  and  the  White  Pock,  a 
highly  contagious  disease  among  milch  cows  and  to 
the  milkers,  quickly  causing  vesications  and  deep  ulcer- 
ations, often  or  almost  always  confounded  by  them 
with  the  true  vaccine,  and  certainly  not  readily  distin- 
guishable in  all  its  stages  by  better-informed  persons 
than  milkers."*  In  1838-9,  Ceely  saw  a  number  of 
animals  in  a  shed,  which  had  scarcely  recovered  from 
the  vaccine  disease,  affected  with  white-pock,  in  conse- 
quence of  the  introduction  from  another  shed  of  a  cow 
who  was  suffering  with  it ;  and  several  of  these  animals 
continued  under  its  influence  for  two  or  three  weeks,  f 
9.  Diagnosis  of  true  Cow-pox. — Although  the  care- 
ful observer  will  find  broad  and  palpable  grounds  of 
distinction  between  vaccinia  and  white-pock,  in  the 
character  of  the  genuine  vaccine  eruption,  its  cellular 
structure,  its  hard  and  knotty  feel,  its  glistening  aspect, 
its  tardy  and  progressive  changes  to  the  vesicular  form, 
its  central  depression  and  its  late  acumination,  the 
necessity  for  caution  and  accuracy  of  diagnosis  must 
be  borne  in  mind.     Jenner  himself  pointed  out  that 

*  See  Ceely,  Transact,  etc.,  vol.  viii.  p.  297         t  Ibid.,  p.  329. 


20  HANDBOOK   OF   VACCINATION. 

milkers  were  very  liable  to  contract  infection  from 
spurious  pocks,  and  to  acquire  in  consequence  false 
and  delusive  ideas  as  to  their  having  immunity  from 
small-pox ;  and  Ceely  informs  us  that  he  has  also,  in 
several  instances,  known  milkers  who  undoubtedly  had 
made  this  mistake  suffer  afterward  from  small-pox, 
while  in  other  instances  he  has  discovered  the  mistake 
they  had  made  in  time  to  save  the  subjects  of  it  from 
small-pox,  by  performing  successful  vaccination  in  the 
ordinary  way.  The  white  or  blister-pock  in  the  human 
subject  exhibits  sometimes,  in  fact,  an  appearance  ex- 
ceedingly like  that  of  real  cow-pox,  so  that,  as  is  the 
case  with  the  two  diseases  in  the  cow,  some  care  may 
be  necessary  to  distinguish  them.  It  is  communicable 
by  inoculation  from  one  human  subject  to  another,* 
and  may  be  communicated  repeatedly  to  the  same 
subject,  f 

*  Mr.  Ceely  has  been  kind  enough  to  show  me  drawings  of 
three  cases  of  casual  blister-pock  on  the  hands  of  milkers,  in 
one  of  which  the  appearance  of  the  vesicles  singularly  resem- 
bles that  of  true  vaccine,  and  he  tells  me  that  some  attention 
was  needed  for  a  correct  discrimination.  He  has  also  shown 
me  a  drawing  exhibiting  the  progress  of  blister-pock  on  a  man 
experimentally  inoculated  with  it  from  a  milker.  Complete 
vesicles  were  formed,  with  some  areola,  by  the  second  day ;  the 
vesicles  and  areola  were  fully  developed  by  the  third  day,  and 
had  then  very  considerable  resemblance  to  cow-pox  at  its  full 
or  eighth-day  development ;  by  the  fifth  day  desiccation  had 
taken  place,  and  the  areola  was  declining. 

f  Mr.  Ceely  informs  me  that  he  has  experimentally  inocu- 
lated himself  successfully  three  or  four  times  with  the  virus  of 
white  or  blister-pock.  Other  diseases  of  the  cow  besides 
white-pock  may  be  contracted  by  milkers  and  communicated 
from   them  to  other  human  subjects.     A  case  is  related  by 


OF  THE  NATURAL    COW-POX.  21 

10.  Supposed  Origin  of  Cow-pox  from  "Grease." — 
Singularly  enough,  the  cow-pox  was  not  considered 
by  Jenner  to  be  a  natural  disease  of  the  cow  at  all, 
but  was  regarded  by  him  as  invariably  induced  from 
an  analogous  disease  on  the  heels  of  the  horse  (the 
horse-pox,  see  Chap.  II.),  which,  however,  at  first  he 
confounded  with  the  grease.  It  so  happened  that  all 
the  cases  of  cow-pox — all  the  first-infected  cases  in 
dairies — which  had  presented  themselves  to  his  obser- 
vation, or  concerning  which  he  had  been  able  to  inform 
himself,  had  been  in  animals  milked  by  men  who  had 
sores  on  their  hands  contracted  from  dressing  the  heels 
of  horses  affected  with  this  so-called  "grease;"  and  that, 
so  far  as  he  could  learn,  the  cow-pox  never  appeared 
in  dairies  in  which  women  were  exclusively  employed 
in  milking.  He  found,  too,  that  the  sores  contracted 
by  these  men  from  horses  were  in  appearance  like  the 
sores  induced  in  milkers  by  cow-pox,  and  that,  when 
the  matter  of  them  was  inoculated  on  the  human  sub- 
ject, it  produced  effects  exactly  analogous  to  those  re- 
sulting from  the  inoculation  of  the  cow-pox.  And  he 
concluded  that  the  source  of  infection  in  the  cow  was 
always  "a  peculiar  morbid  matter  arising  in  the  horse," 
expressing  himself  as  well  convinced  "that  it  (the  cow- 
pox)  never  appears  among  cows  (except  it  can  be 
traced  to  a  cow  introduced  among  the  general  herd 
which  had  been  previously  infected,  or  to  an  infected 
servant)  unless  they  have  been  milked  by  some  one 

Ceely  in  which  a  whole  family  (a  wife  and  five  children) 
labored  under  &  pustular  disease  of  the  character  of  ecthyma, 
from  infection  by  the  father,  who  had  himself  caught  the 
disease  from  a  cow,  described  as  being  in  a  terrible  condition. 
(Trans.  Prov.  Med.  and  Surg.  Assoc.,  vol.  x.  p.  235.) 

3 


22  HANDBOOK  OF   VACCINATION. 

who,  at  the  same  time,  has  the  care  of  a  horse  affected 
with  diseased  heels."*  Undoubtedly  he  was  so  far 
right,  that  the  cow-pox  and  the  horse-pox  have  a  com- 
mon specific  infection ;  and  it  is  equally  unquestionable 
that  the  disease  in  the  cow  must,  in  very  many  of  the 
instances  in  which  it  has  been  met  with,  have  had  the 
origin  which  Jeriner  pointed  out ;  but  the  disease  (for 
whether  we  call  it  cow-pox  or  horse-pox  it  is  the  same 
disease)  has  also  been  met  with  in  each  of  these  classes 
of  animals  independently  of  the  other  on  so  many  occa- 
sions, that  we  cannot  deny  it  to  be  as  much  a  natural 
or  spontaneous  disease  in  the  one  class  as  it  is  in  the 
other,  f 

11.  Geographical  Distribution  of  Cow-pox,  and  cir- 
cumstances affecting  its  appearance  and  spread. — 
The  cow-pox  has  been  met  with  in  every  climate — all 
over  Europe,  in  Asia,  in  North  and  in  South  America. 

*  An  Inquiry  into  the  Causes  and  Effects  of  the  Variolas 
Vaccinae,  p.  46. 

f  Pearson,  in  1798,  pointed  out  that  the  cow-pox  had  been 
met  with  in  farms  where  the  milkers  had  nothing  to  do  with 
horses,  where  no  horses  had  grease,  and  even  where  there  were 
no  horses  on  the  farm  at  all.  Sacco  found  it  in  cows  quite 
isolated,  who  had  been  in  no  communication  at  all  with 
horses,  sound  or  ill.  Hering  says  that  in  Wirtemberg  (where 
cow-pox  has  been  so  frequently  seen)  the  cows  are  (except  in 
very  large  dairies)  exclusively  milked  by  women,  as  the  horses 
are  exclusively  tended  by  men ;  and  in  most  cases  where  cow- 
pox  was  found,  there  were  no  horses  on  the  cow-farms.  (Ueber 
Kuhpocken  an  Kiihen,  p.  9.)  And  Ceelysays:  "For  many 
years  the  spontaneous  origin  of  the  Variola?  Vaccina?  in  the 
cow  has  not  been  doubted  here.  In  all  the  cases  that  I  have 
noticed,  I  never  could  discover  the  probability  of  any  other 
source."  (Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p. 
300.) 


OF  THE  NATURAL    COW-POX.  23 

Jenner  found  that  the  oldest  farmers  in  Gloucestershire 
had  been  familiar  with  it  in  their  earliest  days,  and  the 
disease  had  not  passed  unnoticed  on  the  continent  of 
Europe,  though  previous  to  his  great  discovery  no  par- 
ticular interest  attached  to  it.  But  soon  after  this  in- 
terest had  been  awakened  by  his  publications,  cow-pox 
was  found  either  actually  existing,  or  to  have  been  of 
recent  occurrence,  in  the  dairies  of  London,  in  various 
counties  of  England,  in  different  parts  of  Germany,  in 
the  plains  of  Lombardy,  in  Massachusetts,  in  Connec- 
ticut, and  in  Peru.  After  the  first  ardor  of  search  had 
relaxed,  there  were  for  many  years  but  few  recorded 
instances  of  the  disease  being  found,  and  it  was  be- 
lieved to  have  become  much  rarer;  in  great  measure, 
no  doubt,  because  it  was  less  sought  for.  Since  1824, 
interest  in  the  search  having  in  the  mean  while  been 
renewed,  numerous  outbreaks — sporadic  or  epizootic — 
have  been  reported;  and,  without  by  any  means  in- 
dorsing the  statements  of  Sacco  and  Hering  as  to  the 
extent  to  which,  wherever  there  are  large  herds  of 
cows,  diligent  search  may  be  expected  to  discover  cow- 
pox,  there  can  be  no  doubt  that  much  more  would  be 
found  than  really  is  found,  if  it  were  only  looked  for. 
Still  the  balance  of  evidence  seems  to  be  that,  in  England 
at  all  events,  the  disease  is  not  so  common  now  as  it 
at  one  time  was ;  and  there  is  one  obvious  reason,  I 
think,  why  this  should  be  so.  Undoubtedly,  infected 
milkers  were  great  agents  in  conveying  the  disease 
from  herd  to  herd,  from  dairy  to  dairy;  but  milkers 
nowadays,  from  having  been  vaccinated,  are  not  them- 
selves susceptible  of  the  infection  of  cow-pox  to  the 
extent  that  their  predecessors  were,  and  only  occa- 
sionally, in  fact,  contract  the  disease.     Another  reason 


24  HANDBOOK  OF  VACCINATION. 

also,  as  will  presently  appear,  may  be  the  much  less 
diffusion  now  than  formerly  of  the  variolous  poison. 
But  under  any  circumstances  we  must  allow  that  the 
cow-pox  of  the  cow,  like  small-pox  and  other  epidemics 
in  man,  has  its  periods  of  prevalence  and  of  compara- 
tive absence. 

In  some  localities  cow-pox  is  noticed  to  recur  again 
and  again,  while  in  others  we  have  no  account  of  it 
except  as  being  occasionally  seen.  This  does  not  ap- 
pear to  depend  on  any  conditions  that  can  be  traced. 
Soil  and  elevation  have  apparently  no  influence.  In 
the  Yale  of  Aylesbury,  where  the  disease  has  been 
long  known  and  recurs  at  irregular  intervals,  it  is  met 
with  as  much  on  the  hills  as  in  the  valley.  It  is  found 
frequently  recurring  in  the  broad  pastures  of  the  Bridge- 
water  level,  and  in  the  very  vale  in  which  Jenner's  own 
observations  of  it  were  first  made — the  Yale  of  Glou- 
cester.* The  period  of  the  year  in  which  it  has  been 
most  frequently  noticed  to  manifest  itself  is  the  spring, 
especially  in  the  months  of  May  and  June.  Of  sixty- 
nine  discoveries  of  the  disease  made  in  eleven  years  in 
Wirtemberg,  no  fewer  than  thirty-one  were  made  in 
one  or  other  of  these  two  months.  The  practitioners 
who  have  noticed  it  in  the  Yale  of  Gloucester,  etc., 
state  that  it  usually  appears  in  April,  May,  or  June. 
Ceely  has  met  with  it  at  all  periods  of  the  year  from 
August  to  June,  but  rarely  in  the  height  of  summer. 
It  may  occur  under  any  condition  of  feeding,  though 
Hering  attributes  much  to  the  change  from  dry  to 
moist  food,  from  stall-feeding  to  pasturage,  which  takes 

*  Sixth  Keport  of  Medical  Officer  of  the  Privy  Council, 
p.  10. 


OF  THE  NATURAL    COW-POX.  25 

place  in  the  spring-time.  It  very  much  more  often 
occurs  sporadically  or  in  solitary  instances,  than  as  an 
epizootic  ;  but  when  the  disease  has  found  its  way  into 
a  dairy,  it  will  often,  unless  precautions  be  taken, 
rapidly  spread,  so  that  in  ten  or  twelve  days  many 
animals  will  be  found  to  have  been  affected  in  succes- 
sion ;  and  in  a  dairy  of,  say,  twenty-five  cows,  few  will 
have  escaped  the  disease  by  the  end  of  the  third  week. 
Although  the  hands  of  the  milkers  are  generally  the 
great  agents  of  this  extension,  where  it  occurs,  by  con- 
veying the  disease  from  animal  to  animal,  there  is 
every  reason  to  believe  that  the  natural  form  of  the 
disease  exhibits  itself  on  more  than  one  animal  in  differ- 
ent parts  of  the  same  dairy.  Animals  differ  from  one 
another  in  their  degree  of  susceptibility  to  cow-pox, 
and  Ceely  states  that  he  never  remembers  to  have  seen 
a  dairy  in  which  two  or  three  cows,  equally  exposed 
with  the  others  to  casual  infection,  had  not  escaped. 
One  attack  of  the  disease  is  believed  to  confer,  as  a 
rule,  immunity  from  further  attacks. 

12.  Artificial  production  of  Cow-pox  in  the  Cow. — 
The  vaccine  disease  may  be  designedly  induced  in  the 
cow  by  inoculation  in  various  ways :  (a)  with  lymph 
taken  direct  from  other  cows  suffering  from  the  natural, 
casual,  or  inoculated  form  of  the  disease  ;  (b)  with  the 
lymph  of  the  horse-pox — by  equination;  (c)  with 
lymph  which,  derived  originally  from  cow  or  horse, 
has  passed  through  the  human  system  and  become  for 
a  longer  or  shorter  time  humanized — by  retro-vaccina- 
tion; (d)  with  the  matter  of  human  variola — by  vario- 
lation. In  all  these  forms  of  inoculation,  however,  the 
production  of  vesicles  is  limited  entirely,  or  almost  ex- 

3* 


26  HANDBOOK  OF   VACCINATION. 

clusively,  to  the  points  of  inoculation.  In  other  re- 
spects the  course  of  the  disease  is  essentially  the  same 
as  that  of  the  natural  or  casual  disease ;  but  usually  the 
papular  stage  is  not  well  marked,  and  the  local  phe- 
nomena, especially  in  the  case  of  inoculation  with 
humanized  lymph,  or  with  cow-lymph  that  (as  stated) 
has  been  passed  through  the  bodies  of  several  cows 
successively,*  are  less  active.  Though  in  the  ox  tribe 
the  female  alone  exhibits  the  natural  cow-pox,  that 
disease  is  producible  in  the  male  as  readily  as  in  the 
female  by  inoculation. 

(a)  By  Inoculation  with  Cow-lymph. — Our  best 
account  of  inoculation  with  lymph  taken  from  the 
natural  or  casual  form  of  cow-pox  is  that  given  by 
Ceely,  who,  with  lymph  taken  from  milch  cows  at  a 
time  when  the  variola?  vaccinae  were  prevailing  in 
many  of  the  dairies,  inoculated  some  young  heifers 
about  ten  months  old.  The  parts  selected  for  experi- 
ment were  the  inside  of  the  ear,  the  teats,  and  the  soft 
and  vascular  structure  on  and  near  the  vulva.  The 
punctures  inflamed  early,  as  early  as  the  second  day, 
but  the  papular  stage  was  not  well  marked,  and  was 
apparently  retarded  ;  the  vesicles  were  normal  in  char- 
acter, but  they  declined  by  the  eleventh  day ;  much 
tumefaction,  however,  of  the  integuments  on  the  teats 
remained  till  the  thirteenth  day.  When  the  crusts  fell 
spontaneously  at  the  proper  time,  they  left  a  moder- 
ately deep  smooth  scar ;  but  if  prematurely  removed  a 
deep  erosion  of  the  skin  ensued.  There  was  slight  ac- 
celeration of  the  pulse,  but  no  other  sign  of  general  in- 
disposition.    Lymph  taken  from  the  vesicles  thus  in- 

*  See  note  2,  p.  27. 


OF  THE  NATURAL    COW-POX.  2*1 

duced  and  inserted  in  the  human  subject  produced  the 
effects  ordinarily  noticed  from  the  use  of  primary  cow- 
lymph,  except  that  the  induration  and  inflammation  of 
the  base  of  the  vesicles  were  less  considerable,  and  the 
resulting  scars  less  deep,  though  remarkably  well  de- 
fined and  extending  through  two-thirds  of  the  substance 
of  the  corium.*  When  primary  cow-lymph  has  been 
transmitted  through  several  cows  in  succession,  the 
affection  it  produces  in  the  animals  appears,  according 
to  the  accounts  given,  to  be  much  less  active,  and  to 
run  a  more  rapid  course. f     There  is,  at  the  end  of 

*  Ceely,  in  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii. 
p.  352. 

f  "Rapport  de  l'Acade'mie  Imperiale  de  Medecine  sur  les 
Vaccinations  pendant  1'AnnSe  1864."  Notwithstanding  the 
positive  and  repeated  assertions  of  M.  de  Paul,  the  reporter  of 
the  Vaccine  Commission  of  the  Academie,  that  the  lymph, 
the  effects  of  which  are  above  described,  was  cow-lymph, 
passed  from  animal,  to  animal  without  having  ever  gone  through 
the  human  system,  I  apprehend  there  can  be  no  doubt  that  it 
was,  as  repeatedly  urged  by  numerous  members  of  the  Acade- 
mie, lymph  of  retro-vaccine  origin.  It  was  lymph  which  had 
been  passed  through  animals  since  1858,  the  original  lymph, 
it  was  said,  being  lymph  direct  from  the  cow  obtained  at  that 
time,  by  the  then  Neapolitan  Ambassador  in  England,  from 
her  Majesty  Queen  Victoria  (!),  and  sent  by  him  to  M.  Negri, 
at  Naples.  What  is  meant  is,  I  presume,  that  it  was  procured 
from  the  National  Vaccine  Establishment.  Anyhow,  there 
was  no  cow-pox  among  the  royal  herds  in  1858,  nor,  as  I 
have  ascertained,  has  that  disease  ever  occurred  among  them 
at  any  time  since  they  have,  been  under  their  present  manage- 
ment, which  dates  back  as  far  as  1852.  Neither  was  any  cow- 
lymph  whatever  sent  out  from  the  establishment  in  1858;  nor 
is  there  any  record  of  the  natural  cow-pox  having  been  seen 
in  tha^year  in  England  at  all.  Still,  with  this  explanation, 
I  have  retained   the  description   in   the  text,  M  it  is  at  all 


28  HANDBOOK  OF    VACCINATION. 

thirty  hours,  slight  inflammatory  action ;  on  the  third 
day,  well-marked  redness  and  inflammation ;  on  the 
fourth  day,  the  formation  of  an  elevated  papule,  very 
recognizable  by  the  touch ;  on  the  fifth  day,  develop- 
ment of  a  vesicle  with  an  inflammatory  areola ;  the 
vesicle  and  areola  extend  on  the  sixth  day,  and  by  the 
seventh  day  desiccation  begins.  The  crust  falls  from 
the  fourteenth  to  the  twentieth  day.  From  these 
vesicles,  lymph,  which  is  most  intense  on  the  fifth  or 
sixth  day,  and  comparatively  of  little  value  afterward, 
is  more  or  less  difficult  of  attainment.  Some,  in  order 
to  get  it,  even  resort  to  cutting  away  the  whole  of  the 
vesicle  and  then  scraping  its  inner  surface  strongly,  so 
as  to  get  a  magma  of  lymph  and  dermal  tissue  ;  others 
content  themselves  with  opening  the  vesicle  superfi- 
cially, and  squeezing  the  base  with  forceps  and  collect- 
ing the  liquid  which  exudes.  The  effects  produced  by 
this  lymph,  when  transferred  to  the  human  subject, 
will  be  subsequently  stated  (§  45). 

(b)  By  Equination. — The  casual  equination  of  cows 
must  have  taken  place  hundreds  of  times,  as    already 

events  an  account  of  the  effects  of  lymph  which  (whatever  its 
origin)  has  made  a  great  number  of  transits  through  animals. 
In  the  spring  of  last  year,  the  natural  cow-pox  having  been 
met  with  at  Beaugency,  in  the  department  of  Loiret,  in 
France,  the  lymph  derived  from  that  source  has  been  con- 
tinued through  animals,  and  I  was  in  great  hopes  that  I  might 
have  found  somewhere  a  description  of  the  effects  which  this 
lymph  produced  on  cows  after  a  number  of  continuous  inocu- 
lations, but  I  have  searched  in  vain  for  such  account  in  all  the 
ordinary  channels  of  information  which  were  accessible  to  me. 
Probably  the  effects  after  several  transmissions  are  much  the 
same  as  those  of  humanized  lymph,  and  no  special  description 
has  been  thought  necessary. 


OF  THE  NATURAL   COW-POX.  29 

stated,  producing  what  was  regarded  as  natural  cow- 
pox  ;  and  several  successful  experimental  inoculations 
have  also  been  made.  The  phenomena  of  one  of  these 
inoculations  with  lymph  taken  directly  from  the  pri- 
mary equine  vesicle,  and  inserted  in  a  young  heifer, 
by  M.  Lafosse  of  Toulouse,  in  the  spring  of  1860,  are 
thus  stated  by  him.  Four  punctures  having  been 
made,  one  on  each  dug,  there  was,  on  the  sixth  day, 
only  slight  redness  on  the  punctured  spots,  and  a  fresh 
puncture  on  each  nipple  was  made  ;  on  the  ninth  day 
from  the  original  inoculation,  without  any  general 
symptoms  other  than  a  slight  cough  and  diminution  of 
appetite,  there  were  noticed  four  vesicles  each  of  the 
size  of  a  lentil,  firm,  circular,  flattened,  slightly  umbili- 
cated  at  the  center,  which  was  of  a  reddish  color,  the 
circumference  being  silver-gray.  Each  vesicle  had 
round  it  a  delicate  red  areola  with  distinct  induration. 
By  the  next  day  the  vesicles  had  extended  and  were 
more  completely  formed,  and  three  of  them  being  opened 
yielded  lymph,  two  in  very  minute  quantity,  but  the 
other  in  sufficient  amount  to  serve  for  further  experi- 
ments. The  day  following,  the  eleventh,  the  appetite 
had  returned,  the  cough  was  gone,  and  the  vesicles 
were  undergoing  desiccation.  In  ten  days  more,  by 
the  twenty-first  day,  all  the  scabs,  of  genuine  mahogany 
color,  had  fallen,  either  spontaneously  or  from" friction, 
and  had  left  red-colored  depressed  cicatrices.  From 
the  vesicles  that  had  been  opened  on  the  tenth  day, 
another  heifer,  a  horse,  and  some  children  were  inocu- 
lated, and  all  of  them  with  the  result  of  producing  the 
genuine  vaccine  or  equine  disease.* 

*  Rapport  do  l'Academie  Imperiale  do  Modecino  sur  les 
Vaccinations  pendant  l'Annec  1861,  p.  13,  seq. 


30  HANDBOOK  OF   VACCINATION. 

(c)  By  Retro-vaccination.  —  Retro-vaccination,  or 
inoculation  of  cows  with  vaccine  lymph  that  has  been 
passed  through  the  human  body,  or  humanized,  has 
been  performed  times  innumerable.  Generally,  when 
the  operation  is  successful,  there  are  early  local  symp- 
toms, and  the  vesicle  begins  to  form  by  the  third  or 
fourth  day,  and  is  distinctly  formed  so  as  to  yield 
lymph  for  use  by  the  seventh  ;  occasionally  very  little 
result  of  any  kind  is  perceptible  before  the  seventh  day, 
and  no  evidence  of  the  presence  of  lymph  can  be  got 
before  the  ninth  day;  but,  in  either  case,  the  vesicles 
reach  their  acme  by  the  tenth  day,  and  then  decline,  the 
detachment  of  the  crusts  taking  place  from  the  seven- 
teenth or  eighteenth  to  the  twenty-third  or  twenty- 
fourth  day.  Ceely  made  various  discriminative  ex- 
periments, using  (a)  some  very  long  humanized  lymph ; 
(/?)  some  lymph  of  a  stock  which  had  been  derived 
direct  from  the  cow  about  two  years  before  ;  {y)  some 
variola-vaccine  lymph,  or  humanized  lymph,  which  had 
been  originally  produced  in  the  cow  by  the  process  of 
variolation,  and  which  was  then  at  the  nineteenth  re- 
move; (3)  some  retro-vaccine  lymph,  or  humanized 
lymph  that  had  been  passed  through  the  cow,  then  re- 
transferred  to  the  human  subject,  and  taken  again  from 
the  human  subject  at  the  fifth  remove  ;  but  whatever 
the  source  of  the  lymph  and  whatever  its  age,  he  found 
that,  if  it  were  only  good  lymph,  it  succeeded  equally 
often,  and  excited  equally  perfect  and  productive  vesicles. 
Only  in  the  experiment  with  variola-vaccine  lymph  it 
happened  that  there  was,  in  the  particular  case  de- 
tailed, early  rupture  of  the  vesicles  (by  the  eighth  day), 
and  a  much  less  perfect  crust  than  in  the  other  cases, 
with  absence  of  that  marginal  induration  which  is  or- 


OF  THE  NATURAL   COW-rOX.  31 

dinarily  met  with  from  the  period  when  the  vesicle  is 
fully  developed  up  to  the  fourteenth  or  sixteenth  day.* 
The  most  conflicting  statements  have  been  made  as  to 
the  facility  with  which  cows  may  be  infected  with  hu- 
manized vaccine  lymph.  According  to  Heim,  Ilering, 
and  Hausmann,  it  is  an  experiment  only  rarely  suc- 
cessful, perhaps  once  out  often  or  a  dozen  trials;  Fiard 
met  with  only  six  or  seven  very  doubtful  successes  in 
seventy  experiments ;  Viborg  and  Ritter  were  quite 
unable  to  succeed :  on  the  other  hand,  Caque  at  Rheims, 
Husson  and  Tenier  at  Paris  and  Versailles,  Sacco  at 
Milan,  and  Hellwag  at  Eutin,  in  the  early  days  of 
vaccination,  and  more  lately  Neumann  at  Utrecht, 
Billing  at  Stockholm  (in  1832),  Lentin  in  Weimar  (in 
1835),  Prinz  at  Dresden  (in  1838),  and  others,  have 
experienced  no  great  difficulty.  Carganico  of  Darkeh- 
men  succeeded  every  spring  for  several  successive 
years;  Magleari  of  Naples  professes  to  succeed  "jour- 
nellemcnt ;"  while  that  excellent  and  justly  distin- 
guished authority,  M.  Bousquet,  says  that  to  him 
"e'est  un  jeu  que  de  transmettre,"  etc.  Much,  no 
doubt,  depends  on  the  lymph  employed,  and  much,  as 
Bousquet  justly  observes,  on  choosing  the  animals  to 
be  experimented  on.  Young  cows,  and  particularly 
heifers,  should  be  selected.  No  doubt,  even  then,  it 
has  been  generally  found  more  difficult  to  infect  the 
cows  with  humanized  than  with  cow-lymph ;  but  the 
results  of  the  extensive  vaccinations  of  cattle  carried 
on  in  England  in  1865-6,  during  the  short  time  that  a 
hope  was  entertained  that  vaccination  might  prove  a 
prophylactic  against  cattle-plague, — a  very  large  num- 

*  Ceely,  in  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii. 
pp.  354-365. 

\ 


32  HANDBOOK  OF   VACCINATION. 

ber  of  which  vaccinations  were  done  with  lymph  col- 
lected from  children,  and  others  with  retro-vaccine 
lymph  carried  on  from  cow  to  cow, — showed  that  in 
either  way,  with  due  care,  successful  results  might  be 
very  frequently  attained.  In  Mr.  Ceely's  original  ex- 
periments it  was  distinctly  made  out  that  the  age  of 
the  lymph,  the  length  of  time  that  it  had  been  human- 
ized, made  not  the  slightest  difference  as  to  its  taking 
power  when  retransferred  to  cows ;  and  the  same  has 
been  observed  in  some  experiments  recently  made  by 
M.  Chauveau  and  others  at  Lyons.*  M.  Chauveau 
and  his  colleagues,  in  the  course  of  these  experiments, 
took  occasion  also  to  compare  the  effect  on  cows  of 
long-humanized  lymph  directly  transferred  to  them, 
and  of  unhumanized  cow-lymph  (as  they  supposed  it 
to  be)  which  had  undergone  a  series  of  transmissions 
through  the  bodies  of  animals,f  and  were  unable  to 
detect  any  difference  either  as  to  the  facility  of  taking 
or  as  to  the  local  effects  induced.  When  lymph  raised 
in  cows  by  retro-vaccination  is  vaccinated  back  to  the 
human  subject,  it  produces,  though  with  less  infective- 
ness  during  the  first  two  or  three  removes, — that  is, 
until  it  has  again  become  humanized, — the  results  of 
ordinary  vaccination  (§  46). 

(d)  By  Variolation. — The  variolation  of  the  cow, 
or  production  of  vaccine  by  inoculation  with  the  lymph 
of  human  variola,  will  be  considered  in  Chapter  IV. 

*  Vaccine  et  Variole :  Kapport  par  MM.  Chauveau,  etc., 
Memoires  et  Comptes  Eendus  de  la  Societe  des  Sci.  Med.  de 
Lyon,  tome  v. 

f  The  lymph  they  used,  however,  was  really  lymph  of  retro- 
vaccine  origin,  but  which  had  undergone  a  large  number  of 
transits  through  animals.  It  was  the  lymph  referred  to  in 
note  2,  p.  27. 


OF  THE  IIORSE-rOX.  33 


CHAPTER    II 


OF  THE  HORSE-POX. 


13.  Horse-pox  ;  its  Relations  to  Cow-pox.  —  The 
horse  is  subject,  like  the  cow,  to  a  specific  eruptive 
fever  resulting  in  the  development  of  a  pock,  the  mate- 
rial of  which  has  the  same  property  as  the  fluid  of  cow- 
pox,  of  protecting  the  human  system,  when  inoculated 
with  it,  from  small-pox.  This  pock  has  the  outward 
appearance  and  the  anatomical  structure  which  distin- 
guish the  vesicles  of  cow-pox.  The  chief  points  in 
which  the  disease,  as  seen  in  the  horse,  differs  from 
that  in  the  cow  are — (1)  the  locality  of  the  eruption, 
which  is  chiefly  on  the  heels,  and  on  the  na-o-labial 
mucous  membrane ;  (2)  the  tendency  of  the  eruption 
in  some  cases  to  become  generalized  over  the  body; 
and  (3)  its  appearance  in  the  male  as  well  as  in  the 
female,  horses  being  subject  to  it  as  well  as  mares. 

14.  Its  Relations  to  "Grease." — I  have  already 
stated  (§  10)  that  this  disease  was  at  first  confounded 
by  Jenner  with  that  familiarly  called  "the  Grease," 
an  affection  with  which  it  may  and  very  frequently 
does  coexist,  but  with  which  it  has  nothing  in  common, 
except  that  both  diseases  manifest  themselves  as  dis- 
charging sores  on  the  same  part  of  the  animal,  viz.,  the 
heels.  From  the  want  of  the  necessary  discrimination 
between  the  two  diseases,  and  the  much  greater  fre- 
quency with  which  the  grease  occurs  than  does  the 

4 


34  HANDBOOK  OF   VACCINATION. 

horse-pox,  it  happened  that  most  of  the  experimental 
inoculations  made  with  the  view  of  infecting  the  cow 
with  grease,  were  unsuccessful.  Several  successes, 
however,  were  met  with  in  cases  in  which  the  true 
equine  matter  had  chanced  to  be  got  hold  of.  Mr. 
Tanner,  a  veterinary  surgeon  at  Rockhampton,  so 
early  as  1800,  raised  a  perfect  vaccine  vesicle  on  the 
teat  of  a  cow  by  first  removing  a  scab  from  the  sur- 
face of  an  accidental  sore,  and  then  rubbing  over  the 
sore  the  limpid  matter  taken  from  the  heels  of  a  horse 
afflicted  with  what  he  regarded  as  grease  ;  lymph  taken 
from  the  vesicle  thus  raised  was  successfully  transferred 
to  the  human  subject,  and  a  stock  of  vaccine  thus  ob- 
tained, some  of  which  was  sent  to  Jenner,  and  through 
him  to  the  Small-pox  Hospital.*  The  year  following, 
Loy,  among  many  futile  attempts,  succeeded  in  in- 
fecting four  cows,  by  inoculation  with  lymph  from  a 
"  greasy"  horse  which,  with  considerable  indisposition, 
had  a  generalized  eruption,  while  the  horses  "  that  did 
not  communicate  the  disease  had  a  local  affection 
only;"  and  he  was  led  by  the  result  of  his  experiments 
to  distinguish  two  forms  of  grease,  the  acute  and  the 
chronic,  the  former  of  which  alone  he  regarded  as 
capable  of  imparting  the  cow-pox  to  the  cow  or  to  man, 

*  This  experiment  of  Tanner  could  not  have  been  regarded 
as  conclusive  if  it  had  stood  alone,  for  he  had  first  applied  to 
the  sore  some  cow-pox  matter  on  a  thread.  This  cow-pox 
matter  had  been  so  long  kept  that  it  was  not  thought  possible 
by  the  surgeon  who  gave  it  him  for  it  to  be  effective,  and,  in 
fact,  at  the  end.  of  five  days  not  the  smallest  result  was  per- 
ceptible. It  was  then  that  the  matter  of  grease  was  used,  with 
the  effects  stated  in  the  text.  (See  King,  Treatise  on  the  Cow- 
pox,  p.  336.) 


OF  THE  HORSE-POX.  35 

and  then  only  in  case  the  matter  were  taken  at  the 
proper  period  of  the  vesicle.*  In  1803,  Dr.  La  Font, 
a  French  physician  established  a  Salonica,  though  he 
failed  in  infecting  a  cow,  was  successful  in  producing 
the  perfect  vaccine  vesicle  in  two  young  children,  with 
lymph  taken  direct  from  a  horse  suffering  from  a  disease 
which  was  known  to  the  Macedonian  farriers  as 
"grease,"  but  which  they  distinguished  from  ordinary 
grease  by  the  epithet,  "the  variolous,  "f  Coleman, 
whose  early  attempts  had  failed,  at  a  subsequent 
period  succeeded  in  infecting  a  cow  with  matter  taken 
direct  from  the  heels  of  a  horse,  and  in  propagating 
vaccine  from  the  vesicles  thus  induced.  Further  ex- 
periments, with  two  or  three  exceptions  only, J  gave 

*  Loy,  Experiments  on  the  Origin  of  the  Cow-pox,  8vo. 
"Whitby,  1801.  Before  this  distinction  had  been  made  by  Loy, 
Mr.  Lupton,  of  Thame,  in  Oxfordshire,  had  in  1800  (see  Med. 
and  Phys.  Journal,  vol.  iv.,  Nov.  1800)  more  correctly  pointed 
out  that  the  diseaso  of  the  horse,  which  was  analogous  to  cow- 
pox  and  was  communicable  to  the  cow,  was  not  "  the  grease'' 
nor  any  form  of  grease,  but  a  disease  regarded  by  the  farriers 
of  his  neighborhood  as  widely  different  from  it,  and  to  which 
they  gave  the  name  of  the  "scratchy  heel."  The  distinction 
also,  according  to  Mr.  Grose,  of  Winslow,  was  known  in 
Buckinghamshire,  where  the  vaccigenous  complaint  in  the 
horse,  from  the  singularity  of  making  the  fiair  erect,  was  called 
a  "scratchy  heel."  (Ring,  op.  cit.,p.  237.)  Compare  this  ob- 
servation as  to  the  distinctive  character  of  the  disease,  with 
the  description  of  horse-pox  subsequently  given  in  the  text 
(3  15). 

f  De  Carro  in  letter  to  Jenner,  June  21, 1803.  (See  Baron's 
Life  of  Jenner,  vol.  i.  p.  432.) 

X  The  direct  inoculations  from  horses'  heels,  made  by  Viborg 
and  by  Kiihlerton  cows,  and  by  Steinbeck  both  on  cows  and 
children,  though  exception  lias  been  taken  to  then,  will  be 


36  HANDBOOK  OF   VACCINATION. 

negative  results.  But  the  experiments  that  had  suc- 
ceeded, and  the  almost  familiar  fact  that  lymph  taken 
directly  from  vesicles  on  the  hands  of  farriers,  which 
had  been  contracted  by  them  from  the  heels  of  horses, 
was  productive  of  effects  exactly  the  same  as  those  of 
vaccine  lymph — whether  as  regarded  the  phenomena 
induced,  or  the  protection  against  small-pox  imparted 
— left  no  sort  of  doubt  in  England  as  to  the  horse  being 
subject  to  a  disease  identical  with  cow-pox.*  The 
merely  accidental  relation  of  this  disease  to  grease 
was  longer  of  being  generally  understood.  Jenner 
himself,  though  not  at  first,  was  fully  aware  of  it,  as 
his  description  of  the  disease  shows:  "The  skin  of  the 
horse  is  subject  to  an  eruptive  disease  of  a  vesicular 
character,  which  vesicle  contains  a  limpid  fluid,  show- 
ing itself  most  commonly  in  the  heels.  The  legs 
first  become  edematous ;  and  then  fissures  are  ob- 
served.    The  skin  contiguous  to  these  fissures,  when 

admitted,  I  apprehend,  now  to  have  been  genuine  successes. 
Sacco  and  several  others  succeeded  in  producing  on  human 
subjects  perfect  vaccine  vesicles  with  lymph  taken  from  sores 
(vesicles)  on  the  hands  of  individuals,  which  sores  they  were 
quite  satisfied  had  been  derived  from  the  horse  ;  but  the  diffi- 
culty here  was  to  convince  the  skeptical  that  the  origin  as- 
cribed by  them  to  these  sores  was  correct.  Bousquet,  review- 
ing, in  1848,  the  whole  of  the  experiments  and  observations  up 
to  that  time,  declared  himself  unsatisfied  as  to  whether  cow- 
pox  had  ever-been  derived  from  the  horse  or  not.  (Nouveau 
Traite  de  la  Vaccine,  p.  436.) 

*  Jenner  largely  employed  and  diffused  equine  lymph  for 
vaccinating.  (See  Baron's  Life  of  Jenner,  vol.  i.  pp.  254,  428, 
and  vol.  ii.  pp  220-7  and  388.)  At  first  he  had  a  notion  that 
this  lymph  needed  to  be  passed  through  the  cow  before  it  be- 
came protective  against  small-pox,  but  this  idea  he  soon  aban- 
doned. 


OF  THE  HORSE -POX.  37 

accurately  examined,  is  seen  studded  with  small 
vesicles,  surrounded  by  an  areola.  These  vesicles 
contain  the  specific  fluid.  It  is  the  ill-management  of 
the  horse  in  the  stable  that  occasions  the  malady  to 
appear  more  frequently  in  the  heel  than  in  other  parts; 
I  have  detected  it  connected  with  a  sore  on  the  neck 
of  the  horse,  and  on  the  thigh  of  a  colt;"*  and  again, 
"The  matter  which  flows  from  the  fissures  in  the  heels 
will  do  nothing.  It  is  contained  in  vesicles  on  the 
edges  and  the  surrounding  skin."f  The  distinct  na- 
ture of  the  two  diseases  was  afterward  generally  re- 
cognized;! and  at  least  thirty  years  ago  the  horse- 
pox  was  distinguished  by  the  appropriate  name 
"  Variolas  Equinae,"§  but  no  minute  description  of  it 
was  given  by  any  English  observer.  In  France,  from 
the  general  negative  results  of  repeated  inoculations 
from  horses'  heels,  doubts  as  to  the  existence  of  an 
equine  pox  seem  to  have  been  largely  entertained  up 
to  a  very  recent  period ;  but  within  the  last  few  years 
these  doubts  have  been  completely  set  at  rest.  Two 
outbreaks  of  the  disease  among  horses — one  near  Tou- 

*  Baron's  Life  of  Jenner,  vol.  i.  p.  242.  The  date  of  this 
description,  apparently  taken  from  Jenner's  MS.,  is  not  given. 

f  Letter  of  Jenner  to  Moore,  Oct.  1813  ;  Baron's  Life,  etc., 
vol.  ii.  p.  390. 

%  Kahlert  of  Prague,  referred  to  in  note  3,  p.  35,  describing 
the  horse-pox  as  he  met  with  it  in  Bohemia,  insists  on  the  dis- 
tinction between  the  febrile  and  constitutional  equine  disease 
and  the  grease.  A  French  translation  of  his  paper  will  be 
found  in  the  Almanach  de  Karlsbad,  1833.  It  is  entitled  "  Du 
Javart  Preservatif ; "  and  in  it  he  suggests  for  the  disease  he 
describes  (the  vaccigenous  disease)  the  title  of  "Equin  Pre- 
servatif." 

g  Baron's  Life,  etc.,  vol.  ii.  p.  456. 
4* 


38  HANDBOOK  OF   VACCINATION. 

louse  in  I860,  and  one  at  Alfort  in  1863 — gave  rise  to 
inoculations  the  results  of  which  were  acknowledged 
to  be  entirely  unequivocal.  These  outbreaks  were 
carefully  observed,  and  the  phenomena  of  horse-pox 
may  be  considered  as  now  well  made  out. 

15.  Character  and  Course  of  the  Disease. — The 
disease  differs  so  little  in  its  course  from  the  cow-pox 
in  the  cow,  that  very  minute  description  will  scarcely 
be  called  for.  The  chief  distinction  is  as  to  the  part  of 
the  body  affected,  which  in  the  horse  is  principally  the 
legs,  particularly  the  hind-legs;  the  eruption  being 
generally  more  copious  there  than  anywhere  else,  and 
seldom  extending  beyond  the  hocks,  except  as  the  re- 
sult of  auto-inoculation.*  It  is,  no  doubt,  from  its 
great  exposure  to  this  kind  of  inoculation  that,  after 
the  heels,  the  naso-labial  mucous  membrane  is  the 
chief  seat  of  eruption,  f  In  some  cases  the  vesicles 
seen  on  this  membrane  may  be  primary ;  and  there  are 

*  Of  more  than  100  mares  affected  in  the  epizootic  at 
llieumes,  near  Toulouse,  there  were  only  two  in  whom  the 
eruption  extended  to  the  thighs  and  vulva,  and  one  in  whom 
it  manifested  itself  (but  probably  from  self-inoculation)  on  the 
nostrils  and  lfps.  But  in  the  outbreak  at  Alfort,  affection  of 
the  buccal  and  nasal  mucous  membrane  was  much  more  fre- 
quently noticed,  and  a  general  eruption  observed  in  many 
cases. 

f  As  the  first  inoculations  at  Alfort  were  made  from  some 
vesicles  about  the  mouth,  at  a  time  when  the  real  nature^of 
the  disease  from  which  the  horse  was  suffering  was  not  made 
out,  and  when,  in  fact,  he  was  considered  as  having  an 
"  aphthous  stomatitis,"  this  familiar  disease  of  cattle  was  for 
a  short  time  put  down  as  a  new  source  of  cow-pox  !  But  this 
error  received  its  correction  far  more  speedily  than  the  simi- 
lar error  with  rearard  to  grease. 


OF  THE  HORSE-POX.  39 

said  to  have  been  cases  in  which  this  membrane  was 
the  sole  seat  of  eruption.  Occasionally,  especially  in 
certain  epizootics,  the  eruption  has  been  seen  extending 
over  the  body,  in  greater  or  less  abundance,  from  the 
heels  to  the  belly  and  from  the  head  to  the  tail.  This 
general  eruption,  when  it  occurs,  may  come  on  in  the 
course  of  the  disease,  and  after  the  usual  local  symp- 
toms have  manifested  themselves;  or  the  generaliza- 
tion may  be  noticed  from  the  very  outset.  The  course 
of  the  disease  is  this:  there  is  a  period  of  invasion, 
sometimes  accompanied  with  fever,  which,  if  it  occur 
at  all,  is  in  the  great  majority  of  instances  very  trifling; 
then,  on  the  pasterns  and  other  parts  about  to  develop 
the  eruption,  points  are  felt  or  seen,  which  soon  acquire 
prominence  and  take  the  form  of  pimples,  becoming 
rapidly  flattened  and  umbilicated  at  the  center.  These 
by  the  eighth  or  ninth  day  are  fully  developed,  mostly 
circular,  and  of  the  size  of  a  big  lentil,  notably  elevated 
above  the  skin,  resisting  pressure,  and  having  a  well- 
marked  surrounding  induration.  They  have  absolutely 
the  same  structure  as  the  vaccine  or  variolous  vesicle, 
and  yield,  though  generally  in  small  quantity,  a  viscid 
and  slightly  yellowish  lymph.  By  the  ninth,  tenth,  or 
eleventh  day,  many  of  them  burst,  exuding,  often  co- 
piously, a  viscid  serous  or  sero-purulent  fluid ;  incrus- 
tation going  on  progressively  and  forming  scabs  or 
crusts,  which  from  the  fifteenth  to  the  twenty-fifth  day 
detach  themselves,  leaving  whitish  superficial  cica- 
trices. Varieties  are  observed,  as  in  cow-pox,  some  of 
the  vesicles  being  smaller  and  later  than  others,  some 
less  markedly  umbilicated,  some  not  umbilicated  at  all. 
They  are  most  developed  in  the  parts  that  are  naked  or 
have  little  hair,  and  where  the  skin  is  fine.     If  the  hair 


40  HANDBOOK   OF    VACCINATION. 

be  long  and  close,  they  are  smaller  and  less  regular, 
and  attentive  observation  is  often  necessary  to  make 
out  their  existence ;  little  pencils  of  hair  will  be  seen 
standing  up  here  and  there,*  and  if  the  finger  be 
lightly  moved  over  these  spots,  slight  indurations  will 
be  felt,  corresponding  to  pimples  or  vesicles,  which  may 
be  brought  to  light  by  cutting  the  hair  away.  Just  as 
the  cow-pox  among  cows  in  dairies,  the  horse-pox  is 
communicated  from  animal  to  animal  by  casual  inocu- 
lations, immediate  or  mediate,  and  these  inoculations 
are  the  main  cause  of  the  spreading  of  the  disease. 

It  is  evident,  from  the  observations  already  made, 
that  the  disease  has  to  be  distinguished  from  Grease 
on  the  one  hand,  and  Aphtha  epizootica  on  the  other. 

16.  Artificial  Production  of  Horse-pox  by  Inocula- 
tion.— The  horse-pox  has  been  designedly  induced  in 
the  horse,  and  other  animals  of  the  horse  tribe,  by  in- 
oculation— (a)  with  equine  lymph  directly  transferred 
from  horse  to  horse ;  this  was  done  on  numerous  occa- 
sions and  with  great  success,  in  1863,  by  M.  Bouley;f 
(b)  with  equine  lymph  that  had  been  passed  success- 
fully through  a  cow,  producing  in  that  animal  all  the 
phenomena  of  the  genuine  inoculated  cow-pox  ;  this 
was  done  both  in  1860  at  Toulouse,  by  M.  Lafosse,| 
and  in  1863  at  Alfort,  byM.  Bouley,  and  at  the  Jardin 
d'Acclimatisation  at  Paris  ;§  (c)  with  lymph  supposed 
to  be  unhumanized  cow-lymph,  not  primary,  but  the 
product  of  a  series  of  transmissions  of  primary  lymph 

*  See  the  description  of  the  "  scratchy  heel,"  note  1,  p.  35. 
f  Bulletin  de  l'Academie,  tome  xxix.  p.  236. 
J  Kapport  de  l'Academie  Imperiale  de  Medecine  sur  les  Vac- 
cinations pendant  l'Annee  1861. 

§  Bulletin  de  l'Academie,  tome  xxix.  pp.  131-3  and  199. 


OF  THE  IIORSE-POX.  41 

through  animals  of  the  ox  tribe :  this  was  done  by  M. 
Chauveau  and  his  colleagues  ;*  and  (d)  with  ordinary 
humanized  vaccine  lymph ;  an  experiment  thus  made 
in  1862  by  MM.  Rayer  and  De  Paul,  at  Alfort,  re- 
sulted in  the  production  of  eight  well-characterized 
vesicles,  perfectly  circular,  with  central  depression  and 
induration  of  the  whole  surrounding  thickness  of  the 
dermis — a  description  which  fully  justifies  us  in  regard- 
ing the  inoculation 'as  successful,  notwithstanding  that 
the  fluid  obtained  from  the  vesicles,  tried  on  a  single 
baby,  produced  no  effect ;"}"  and  since  then,  M.  Chau- 
veau appears  to  have  used  this  kind  of  lymph  in  several 
successful  inoculations. | 

Although  primary  cow-lymph  has  not,  so  far  as  I 
am  aware,  been  used  on  any  occasion  for  inoculating 
horses,  it  may  be  taken  as  quite  certain  that  such  in- 
oculation would  be  productive  of  the  equine  pox.  And 
there  is  every  probability,  I  think,  that  if  sufficient 
trials  were  made,  the  same  result  might  be  obtained 
from  inoculating  horses,  under  favorable  conditions, 
with  the  matter  of  human  variola ;  although  the  few 
experiments  that  have  hitherto  been  made  with  this 
object  have  either  given  negative  results, — as  those 
reported  by  Badcock,§  by  Lalagade,||  by  Bouley,^f  and 

*  Vaccine  et  Variola,  etc.,  op.  cit.  See,  however,  note  2,  p. 
27,  where  the  origin  of  this  lymph  is  referred  to. 

f  Kapportde  l'Academie  Imperiale  de  Medecine  sur  les  Vac- 
cinations pendant  l'Annec  18G1. 

J  Chauveau,  Des  Conditions  qui  president  au  developpement 
de  la  Vaccine  dite  primitive:  Bull,  de  l'Acad.,  tome  xxxi. 

§  Badcock,  Detail  of  Experiments  confirming  the  Power  of 
Cow-pock,  etc.,  p.  15. 

||  Rapport  de  l'Acad6mie  Imperialo  de  Medecine  sur  les  Vac- 
cinations pendant  l'Annee  1863,  p.  102. 

\  Bulletin  de  l'Acad6mie,  tomo  xxix.  p.  286. 


42  HANDBOOK  OF    VACCINATION. 

by  Le  Blanc  and  De  Paul,*  —  or  have  afforded  re- 
sults such  as  those  obtained  by  M.  Chauveau  and  his 
colleagues,  which  will  be  described  hereafter,  and 
which  lead,  in  their  opinion,  to  an  opposite  conclusion. 
This  subject  will  be  considered  in  Chapter  IV. 

In  the  horse-pox  induced  by  the  ordinary  process  of 
inoculation,  eruption  is  limited,  with  rare,  if  any,  ex- 
ceptions, to  the  points  of  inoculation.  The  local  phe- 
nomena are  less  active  than  in  the  natural  disease,  but 
the  course  of  the  disease  is  essentially  the  same. 

17.  Artificial  production  of  Horse-pox  by  Injection 
of  Lymph. — A  variety  of  inoculation,  viz.,  that  of  in- 
jecting the  liquid  vaccine  lymph  into  the  blood-vessels 
or  lymphatics  of  horses,  has  recently  been  attempted 
by  M.  Chauveau  with  the  most  interesting  results. 
It  occurred  to  him  that  it  might  be  possible  by  this 
method  of  proceeding  to  produce  the  more  extended 
or  generalized  eruption,  which  in  this  tribe  of  animals 
frequently  attends  the  natural,  or,  as  it  is  called,  spon- 
taneous disease.  Accordingly,  he  inoculated  four  old 
horses  by  injecting  some  vaccine  lymph  into  a  blood- 
vessel, and  four  more  by  injection  into  a  lymphatic 
vessel  just  before  its  entrance  into  a  ganglion.  The 
first  series  of  experiments  (those  in  which  the  injection 
was  into  a  blood-vessel)  failed.  But  of  the  animals  in 
the  second  series  (those  inoculated  through  the  lym- 
phatics), the  inoculation  succeeded  in  three  out  of  the 
four,  producing  a  fine  eruption  of  vaccine,  which  had 
all  the  characters  of  the  spontaneous  horse-pox.  One, 
a  horse,  had  a  full  eruption,  commencing  at  the  end  of 
eleven  days,  and  completely  developed  in  three  or  four 

*  Bulletin  de  l'Aeademie,  tome  xxix.  p.  370. 


OF  THE  1I0RSE-P0X.  43 

days  more,  on  the  nostrils  and  lips,  as  well  as  on  the 
hind  heels;  the  second,  a  mare,  injected  from  the  pre- 
ceding, had  isolated  vesicles  disseminated  over  the  body, 
except  the  neck  and  pasterns,  but  chiefly  to  the  mam- 
mary region  and  on  the  lips — the  eruption  commencing 
on  the  eighth  day,  and  continuing  to  appear  up  to  the 
fourteenth ;  and  the  third,  a  mare,  had,  on  the  twelfth 
day,  an  eruption  chiefly  on  the  genital  organs  and  the 
inner  surface  of  the  thighs.  And  virus  taken  from  the 
eruption  on  each  of  these  animals  produced,  it  is  said, 
regular  vaccine  both  on  the  cow  and  on  children.  M. 
Chauveau,  in  a  later  course  of  experiments,  succeeded 
in  inoculating  a  young  colt  by  two  injections  of  vaccine 
lymph,  at  intervals  of  two  days,  direct  into  the  san- 
guineous system  through  the  jugular  vein ;  vesicles 
beginning  to  appear,  principally  in  the  naso-labial  re- 
gion, in  twelve  days,  and  continuing  to  appear  for  four 
days  more,  the  lymph  of  which  was  found  to  produce 
regular  vaccine  both  on  a  child  and  on  animals  of  the 
ox  tribe.  Following  out  still  further  the  same  idea, 
M.  Chauveau,  by  injecting  vaccine  into  a  pouch  formed 
in  the  subcutaneous  cellular  tissue  on  the  left  side  of 
the  neck  of  a  colt,  but  with  great  care  that  the  lymph 
should  not  touch  the  wounded  skin,  obtained  no  local 
vesicle,  but  an  eruption,  commencing  on  the  tenth  day, 
of  a  few  vesicles  on  the  naso-labial  region.  From  these 
results,  in  connection  with  the  fact  that,  in  nearly  thirty 
successful  inoculations  of  horses  with  vaccine  lymph  in 
the  ordinary  way,  no  general  eruption  followed,  M. 
Chauveau  concludes  the  one  essential  condition  of  a 
generalized  eruption  to  be  that  the  virus  should  not 
pass  through  the  membrane  which  is  the  anatomical 
seat  of  the  vaccine  eruption.     M.  Le  Blanc,  however, 


44  HANDBOOK  OF   VACCINATION. 

states  that  he  has  seen  general  eruption  to  occur  in  a 
case  in  which  inoculation  had  been  done  in  the  ordi- 
nary way,  and  that  he  proved  the  vaccinal  character  of 
the  vesicles  secondarily  developed  by  equinating  suc- 
cessfully from  them  both  horses  and  Tuminants.  It  is 
exceedingly  desirable  that  these  interesting  experi- 
ments of  M.  Chauveau  should  be  repeated.  Young 
colts  appear  more  adapted  for  the  purpose  than  old 
horses.* 


CHAPTER    III. 

OF   POCKS  IN  OTHER    ANIMALS  WHICH    HAVE   BEEN  CON- 
SIDERED  ANALOGOUS   TO    COW-POX   AND    HORSE-POX. 

18.  Sheep-pox By  far  the   most  interesting  and 

important  of  these  is  the  sheep-pox,  "le  claveau,"  or 
"la  clavelee,"  of  the  French — the  Yariola  Ovina,  as  it 
has  been  termed, — a  disease  frequently  met  with  in 
various  parts  of  the  Continent,  but  which  has  made 
its  appearance  in  England  on  three  occasions  only,  viz., 
in  1710-11,  in  1847-50,  and  in  1862.  It  so  far  resem- 
bles the  diseases  already  treated  of  in  the  cow  and 
horse  that  it  is  an  infectious  febrile  disease,  character- 
ized by  a  vesicular  eruption.  But  the  vesicles  have 
neither  the  appearance  nor  the  structure  of  the  vesicles 
of  cow-pox  or  horse-pox.    Their  surface  is  flat  and  not 

*  Chauveau,  Des  Conditions  qui  president  au  developpement 
de  la  Vaccine  dite  primitive  :  Bulletin  de  l'Acad.  Imp.  de 
Med.,  tome  xxxi.  Also,  Comptes  Rendus  de  l'Acad.  des 
Sciences,  tome  lxii.  p.  1118,  and  tome  lxiii.  p.  573. 


OF  POCKS  IN  OTHER   ANIMALS.  45 

umbilicated,  and  their  structure  is  simple  and  unretie- 
ulated,  a  single  puncture  with  a  lancet  serving  to  empty 
a  whole  vesicle.  A  further  important  difference  to  be 
noted  is  in  the  severity  of  the  general  symptoms  which 
attend  sheep-pox,  and  the  very  great  fatality  of  that 
disease;  in  these  respects  it  more  resembles  natural 
small-pox  in  the  human  subject.  It  has  a  period  of  in- 
cubation not  very  different  from  that  of  human  variola. 
It  is  transferable  from  sheep  to  sheep  by  inoculation  or 
"  clavelization."  The  disease  produced  by  this  claveli- 
zation  is  very  considerably  milder  than  the  natural  dis- 
ease, and  imparts  security  to  the  animal  against  a  nat- 
ural attack  of  the  sheep-pox. 

19.  Ovination  of  the  Human  Subject. — The  question 
of  the  relation,  if  any,  which  this  disease  holds  to  cow- 
pox  and  horse-pox — whether  its  material  inoculated  on 
the  cow  or  horse,  or  on  man,  will  produce  the  effects, 
local  and  general,  of  the  vaccine  or  equine  affection — 
and  whether,  conversely,  the  cow-pox  or  horse-pox  can 
be  imparted  to  sheep — is  one  of  considerable  scientific 
interest.  Its  practical  importance  is  limited  entirely 
to  the  effect  which  inoculation  of  the  latter  kind  might 
have  in  protecting  sheep  from  sheep-pox.  Of  the  very 
numerous  attempts  that  have  been  made  to  communi- 
cate the  shcep-pox  to  man,  the  inoculations  of  one  ex- 
perimenter alone  appear  to  have  been  successful ;  but 
the  success  with  which  he  met  was,  according  to  ac- 
counts, as  constant  as  have  been  the  failures  of  other 
observers.  Sacco,  of  Milan,  when  passing  through 
Capua,  in  1804,  saw  accidentally  some  sheep  affected 
with  sheep-pox,  a  disease  which  at  that  time  he  had 
not  before  met  with.  He  took  virus  from  the  finest 
vesicles;   and  with  this  he,  in  conjunction  with  Dr. 

5 


46  HANDBOOK  OF   VACCINATION. 

Legni,  of  Cattolica,  inoculated  six  children,  vaccinating 
two  others  at  the  same  time  with  ordinary  vaccine 
lymph.  lie  did  not  stay  to  watch  the  results,  but  Dr. 
Legni  reported  to  him  a  month  afterward  that  the 
ovmation  had  been  successful,  and  that  no  marked  dif- 
ferences had  been  observable  between  the  vesicles 
produced  by  the  ovine  and  those  produced  by  the  vac- 
cine lymph.  Dr.  Legni  added,  that  he  had  continued 
to  propagate  the  ovine  lymph  on  children.  Sacco,  on 
his  return  to  Milan,  used  what  he  had  remaining  of 
the  ovine  virus  (it  had  been  collected  in  tubes),  but 
unsuccessfully.  Two  years  afterward,  however  (in 
1806),  sheep-pox  again  prevailing  in  Italy,  he  inocu- 
lated five  children  with  virus  taken  from  a  lamb — in- 
serting, in  two  out  of  these  five  children,  the  ovine 
lymph  on  one  arm  and  vaccine  lymph  on  the  other. 
Two  of  the  three  children  in  whom  the  vaccine  lymph 
had  not  been  inserted,  and  one  of  the  two  in  whom  it 
had,  had  each  one  ovine  vesicle ;  the  vaccine  took  effect 
in  both  the  children  in  whom  it  was  employed,  raising 
in  one  of  them  a  single  vesicle,  and  in  the  other  two 
vesicles.  When  the  three  vesicles,  the  products  of 
each  lymph,  the  three  vaccine  and  the  three  ovine, 
were  compared  together,  Sacco  says  he  was  unable  to 
detect  any  difference  of  character  between  them. 
Moreover,  the  two  children  who  had  ovine  vesicles 
only,  were  tested  some  days  afterward  by  small-pox 
inoculation,  but  no  effect  was  produced.  He  inocu- 
lated afterward,  with  ovine  virus,  some  children  at 
Fotidinovo,  and  found  the  results  in  all  to  be  the  pro- 
duction of  vesicles  exactly  like  vaccine ;  and  he  inserted 
ovine  virus  also  in  some  children  and  a  cow  at  Barba- 
rasco.     As  he  was  unable  to  stay  and  watch  the  effects 


OF  POCKS  IN  OTHER  ANIMALS.  47 

in  this  last  series  of  inoculations,  he  left  some  of  the 
cases  in  care  of  a  surgeon,  Dr.  Magnani,  who  reported 
to  him  that  out  of  four  children  the  ovination  had  taken 
in  two,  producing  in  one  of  them  four  vesicles,  and  in 
the  other  a  single  vesicle  only;  that  the  vesicles  were 
like  those  of  vaccine  and  surrounded  by  a  red  circle, 
but  containing  a  liquid  which  was  not  limpid,  but 
serous  and  yellowish;  that  this  liquid,  inoculated  on 
two  children,  produced  vesicles  which  on  the  seventh 
day  were  full  of  limpid  fluid,  with  which  three  others 
were  inoculated ;  and  that  in  all  the  children  of  this 
last  inoculation  vesicles  arose,  the  contents  of  which  on 
the  eighth  day  were  limpid  and  crystalline,  like  the  true 
vaccine  lymph.  He  further  reported  that  on  examina- 
tion of  the  cow,  he  had  found  a  single  vesicle  on  the 
udder,  distended  with  yellow  and  turbid  fluid,  which 
was  inoculated  on  two  children  with  the  usual  effects 
of  vaccination.  Sacco  says  that  ovine  virus  was  in- 
oculated afterward  at  Lucca,  and  that  stocks  of  lymph 
of  this  origin  were  employed  like  vaccine  lymph  for 
vaccinating  purposes,  producing  exactly  the  same 
effects.*  In  other  hands — in  France  as  in  England — 
every  attempt  to  produce  the  vaccine  disease  by  ovina- 
tion has  (save  in  a  single  doubtful  instance)  failed ;  and 
this,  though  the  number  of  experiments  has  been  very 
great,  and  though  a  large  number  of  them  have  been 
conducted  by  men  singularly  versed  in  experiments  of 
the  kind.  Mr.  Marson  and  Mr.  Ceely  have,  between 
them,  performed  not  less  than  250  inoculations  on 
human  subjects  with  the  virus  of  sheep-pox,  and  with 
the  single  equivocal  exception,  the  particulars  of  which 

*  Sacco,  Trattato  di  Vaccinazione,  pp.  145-148. 


48  HANDBOOK  OF   VACCINATION. 

will  be  afterward  stated,  they  failed  to  induce  any- 
thing like  a  vaccine  vesicle.  The  following  is  the  ac- 
count Ceely  gives  of  the  result  of  some  of  his  en- 
deavors: "I  ovinated  twenty-five  subjects  whose  ages 
ranged  from  three  to  fifteen  years,  some  twice  and 
thrice  over;  in  none  were  there  fewer  than  six  punc- 
tures each  time,  making  not  less  than  180  punctures; 
no  specific  dfsease  resulted  ;  but  a  prompt  and  devious 
papular  or  diffuse  inflammation,  or,  more  rarely,  a  com- 
mon local  pustular.  In  the  majority  of  these  twenty- 
five  individuals  the  virus  employed  was  liquid.  When 
very  recently  charged  points  were  used,  subsequent  re- 
inoculation  with  liquid  virus  was  bad  recourse  to,  but 
with  no  other  effect.  Nearly  all  the  above  subjects 
were  shortly  afterward  vaccinated  with  current  vaccine 
lymph,  which  in  each  case  exhibited  the  normal  effects. 
I  may  as  well  add,  also,  that  the  same  kind  of  ovine 
virus  which  did  not  succeed  on  children  took  promptly 
on  sheep."*  Such  uniformity  of  failure  in  the  hands 
of  the  best  of  experimenters,  and  when  every  pains 
were  certainly  taken  to  produce  success,  suggests  the 
possibility  of  fallacy  in  Sacco's  experiments,  and  sug- 
gests it  all  the  more  for  the  very  facility  Avith  which  he 
succeeded;  for  I  agree  with  M.  Bousquet,  that  where 
one  person  succeeds  so  uniformly  that  his  experiments 
appear  to  be  but  an  amusement  to  him  where  every- 
body else's  fail,  there  cannot  but  be  some  ground  for 
hesitation  in  accepting  his  conclusions,  f  A  doubt 
certainly  suggests  itself  to  the  mind,  whether,  in 
Sacco's  experiments,  done  at  the  same  time  with  two 

*  Simonds,  Practical  Treatise  on  Variola  Ovina,  p.  154. 
f  Bulletin  de  l'Academie,  tome  xxix.  p.  585. 


OF  POCKS  IN  OTHER  ANIMALS.  49 

viruses, — the  ovine  and  the  real  vaccine, — some  accident 
might  not  have  occurred  by  which  the  two  may  1  ave 
become  inadvertently  mixed,  or  inadvertently  substi- 
tuted for  one  another.  Similar  accidents,  it  is  well 
known,  not  unfrequently  happened  in  England  with 
variolous  and  with  vaccine  lymph  in  the  early  days  of 
vaccination  (when  the  variolous  and  the  vaccine  in  )cu- 
lations  were  carried  on  by  the  same  practitioners,  at 
the  same  time  and  often  on  the  same  subjects),  giving 
rise  to  phenomena  which,  till  the  cause  of  them  was 
found  out,  greatly  complicated  and  confused  our  un- 
derstanding the  real  characters  of  the  vaccine  disease 
in  the  human  subject.  The  facility  with  which  mis- 
takes of  this  kind  might  occur  when  tubes  and  points 
are  used  (and  we  know  that  Sacco  was  greatly  in  the 
habit  of  using  tubes  to  collect  and  convey  his  lymph 
for  experimental  and  other  inoculations)  is  obvio.is.* 
Still,  among  the  constant  failures  that  have  attended 

*  It  is  impossible  to  mention  the  name  of  Sacco  without  an 
expression  of  gratitude  and  respect  for  the  vast  services  he 
rendered  in  the  diffusion  of  vaccination  in  Italy.  The  int  rest 
he  took  in  the  subject  led  him  to  the  performance  of  innumer- 
able experiments  on  all  sorts  of  animals;  but  the  very  variety 
and  multiplicity  of  these  experiments,  and  the  evidently  casual 
way  in  which  many  of  them  were  done,  are  suggestive  of  a 
state  of  hurry  which  is  not  favorable  to  good  experimentation. 
His  account  of  the  experiments,  and  of  his  manner  of  con- 
ducting them,  is  given  in  very  general  terms,  and  it  is  im- 
possible to  read  it  without  feeling  how  many  details  arew  ant- 
ing to  make  it  satisfactory  and  conclusive.  And  his  conclu- 
sions with  regard  to  the  constitutional  effects  of  vaccination 
on  animals  were  certainly  very  hastily  drawn,  for  he  not  '»nly 
found  vaccination  to  save  sheep  from  sheep-pox,  and  dogs  from 
distemper  and  other  diseases  besides,  but  also  horses  from 
glanders ! 

5* 


50  HANDBOOK  OF   VACCINATION. 

the  attempts  of  all  other  experimenters  to  ovinate  the 
human  subject,  there  has  been  one  apparently  success- 
ful inoculation  which  was  not  Sacco's ;  and  as  this  case 
occurred  to  so  singularly  cautious  and  able  an  experi- 
menter as  Mr.  Marson,  if  he  had  been  satisfied  with 
the  result  we  might  have  been  prepared  to  allow  this 
positive  to  outweigh  the  many  negative  observations 
that  have  been  accumulated.  But  Mr.  Marson  was 
not  satisfied,  and  his  account  of  the  circumstances 
illustrates  admirably,  as  it  appears  to  me,  the  caution 
which  should  be  used  in  drawing  deductions  from  ex- 
periments made  to  determine  doubtful  issues:  "When 
small-pox  appeared  in  this  country  in  the  sheep  in 
1847,"  he  says,  "we  tried  to  communicate  it,  by  inocu- 
lation, to  the  human  subject,  and  thought  we  had  suc- 
ceeded in  doing  so,  and  the  virus  was  carried  on  from 
one  to  another  for  several  weeks  in  succession.  The 
pock  produced  was  very  like  cow-pox,  having  only,  as 
we  thought,  a  bluer  tinge,  and  was  protective  against 
small-pox,  as  we  ascertained  by  inoculating  the  patient 
afterward  with  the  lymph  of  human  variola;  but  we 
had  unfortunately  used  for  the  original  ovination  the 
same  lancet,  instead  of  having  a  new  one,  as  we  ought 
to  have  had,  that  we  had  previously  used  for  vaccina- 
ting ;  and  although  it  was,  as  we  believe,  perfectly  clean, 
and  free  from  vaccine  lymph,  nevertheless,  as  the 
disease  could  not  be  produced  again  in  the  human  sub- 
ject, either  by  Mr.  Ceely,  of  Aylesbury,  who  made  re- 
peated trials  with  the  lymph  of  sheep-pox,  or  by  our- 
selves, the  experiment  was  never  brought  before  the 
medical  profession."* 

*  Art.  "Small-pox,"  in  System  of  Medicine,  ed.  by  J.  B. 
Keynolds,  M.D.,  vol.  i.  p.  433. 


OF  POCKS  IN  OTHER  ANIMALS.  51 

20.  Ovination  of  Cows,  etc. — The  most  careful  en- 
deavors made  on  various  occasions  by  Professor  Si- 
monds, Mr.  Ceely,  and  Mr.  Marson  to  impart  the 
sheep-pox  to  the  cow,*  wholly  failed  ;  and  the  French 
veterinarians,  whose  acquaintance  with  sheep-pox  is 
extensive,  are  all  of  opinion  that  it  cannot  be  commu- 
nicated to  the  ox  tribe  either  by  inoculation  or  by  in- 
fection. M.  Hurtrel  d'Arboral  also  informs  us  that 
attempts  to  inoculate  it  on  other  animals — deer,  pigs, 
dogs,  monkeys,  etc.  —  have  been  alike  unsuccessful. f 
Marson  found  the  goat,  though  an  animal  in  many  re- 
spects so  like  the  sheep,  equally  unsusceptible. 

21.  Vaccination  of  Sheep.  —  But  whatever  uncer- 
tainty may  still  be  considered  to  exist  as  to  the  pro- 
duction of  the  vaccine  disease  in  the  human  subject  by 
ovination,  there  is  none  whatever  that  the  phenomena 
induced  in  sheep  by  inoculation  with  vaccine  lymph  are 
very  different  indeed  from  those  of  the  genuine  vaccine 
disease  as  exhibited  on  the  cow  or  on  man,  or  from 
those  of  inoculated  sheep-pox  in  the  sheep.  There  is 
generally  some  difficulty  in  getting  vaccine  lymph  to 
take  any  effect  on  sheep  at  all,  and  it  is  found  that  in 
nearly  two-thirds  of  the  cases  the  inoculation  requires 
to  be  repeated  once  or  oftener.  "  When  effect  is  pro- 
duced, the  resulting  affection,"  say  Mr.  Marson  and 
Professor  Simonds,  "even  when  developed  to  its  fullest 
extent,  is  very  unlike  the  same  disease  in  the  human 
subject.     In  the  sheep  it  is  but  seldom  anything  more 

*  Simonds,  Practical  Treatise,  etc.,  p.  155;  also  Report  of 
Experiments  made  under  direction  of  the  Lords  of  the  Coun- 
cil as  to  the  Vaccination  of  Sheep,  etc.,  by  Mr.  Marson  and 
Prof.  Simonds  (Pari.  Paper,  1864),  p.  5. 

f  Diction naire  de  Medecine  Vete>inaire,  art.  "Clavelisa- 
tion." 


52  HANDBOOK  OF   VACCINATION. 

than  the  production  of  a  small  papule,  which  occasion- 
ally results  in  the  formation  of  a  minute  vesicle,  or 
more  commonly  a  pustule,  which  is  sometimes,  although 
very  rarely,  surrounded  with  a  slight  areola.  Generally, 
however,  neither  vesication  nor  pustulation  follows,  but 
a  small  scab  is  produced,  which  soon  falls  from  the  site 
of  the  puncture,  leaving  no  trace  behind.  The  disease 
passes  quickly  and  irregularly  through  its  several 
stages,  so  as  to  have  ended  by  the  eighth  or  ninth  day, 
or  not  unfrequently  even  before  this  time.  Lymph  is 
but  rarely  obtainable,  and  never  but  in  the  smallest 
quantity,  and  this  on  the  fifth  or  sixth  day  succeeding 
the  vaccination.  The  effects  are  only  local,  and  the 
animal's  health  never  impaired."*  The  entirely  local 
nature  of  this  affection  is  shown  by  the  fact  that  sheep 
who  have  gone  through  it  are,  on  the  one  hand,  just  as 
susceptible  of  the  action  of  the  vaccine  virus  on  imme- 
diate repetition  of  the  operation  as  if  nothing  had  been 
done  to  them,  and  are,  on  the  other  hand,  not  in  the 
least  protected  against  sheep-pox.  The  description  of 
the  results  of  vaccination  on  sheep,  which  is  given  by 
other  observers,  agrees  closely  with  that  of  JMarson 
and  Simonds,  even  of  those  observers  who,  like  Sacco, 
thought  that  the  sheep  was  constitutionally  affected 
thereby,  and  was,  in  fact,  really  vaccinated.  For  Sacco 
speaks  of  the  vesicles  being  "  mostly  resolved  before 
coming  to  maturity;  the  cutis  detaching  itself  in  small 
scales  from  their  surfaces,  as  from  the  pustules  of  ovine 
variola.  It  is  very  seldom  that  true  vesicles  are  pro- 
duced which  are  succeeded  by  scabs. "f     Still,  by  this 

*  Keport  of  Experiments,  etc.,  p.  6. 

f  Sacco,  as  quoted  by  Simonds,  Pract.  Treatise,  etc.,  p.  142. 


OF  POCKS  IN  OTHER  ANIMALS.  53 

affection,  such  as  it  was,  Sacco  hoped,  and  believed, 
and  taught  that  sbeep  might  be  protected  against  sheep- 
pox.  Unfortunately,  this  has  turned  out  not  to  be  the 
case.  No  fact  is  more  conclusively  established  than 
the  utter  worthlessness  of  vaccination  for  saving  sheep 
from  sheep-pox.*  The  effects  of  vaccination  in  the 
sheep,  such  as  they  are,  are  entirely  local,  not  in  the 
least  degree  constitutional ;  and  this  result  is  calcu- 
lated, I  think,  to  throw  further  doubt  on  those  experi- 
ments by  which  the  converse — the  production  of  con- 
stitutional vaccinia  in  the  human  subject  by  inoculation 
with  the  lymph  of  sheep-pox — has  been  supposed  by 
some  to  be  established. 

22.  Variolation  of  Sheep. — It  may  be  added  that 
attempts  to  inoculate  sheep  with  human  variola  have 
equally  failed.  Mr.  Marson  tried  this  on  a  hundred 
sheep,  six  punctures  being  made  on  each  sheep,  but 
the  results  were  essentially  the  same,  both  locally  and 
constitutionally,  as  those  obtained  with  vaccine  lymph. 
Sheep  in  whom  the  variolous  virus  had  produced  a  local 

*  Keport  of  Experiments,  etc.:  also  Simonds,  Pract.  Treatise, 
etc.,  chap.  vi.  Hurtrel  d  Arboral,  Huzard,  and  other  French 
veterinarians  who  have  experimented  on  a  large  scale  bear 
unanimous  testimony  to  the  same  effect.  It  is  not  a  little 
surprising,  therefore,  to  find  M.  de  Paul,  the  Director  of  the 
Vaccinations  of  the  Academie  Imp.  de  Med.  at  Paris,  stating 
to  the  Academy  that  vaccination  takes  perfectly  (prend  a  mer- 
veille)  on  sheep,  and  gives  them  complete  protection  against 
sheep-pox  ;  that  sheep-pox  matter  inoculated  on  cows  produces 
perfect  vaccine,  etc.  etc.  (Bull,  de  l'Acad.,  tome  xxix.)  In 
a  former  note  (note  2,  p.  27),  I  referred  to  very  positive 
statements  made,  and  insisted  on,  by  M.  de  Paul  on  very  in- 
sufficient evidence,  but  the  present  statements  are  in  the  teeth 
of  all  evidence. 


54  HANDBOOK  OF  VACCINATION. 

effect  were  found  still  susceptible  of  the  sheep-pox,  and 
some  of  them  being  submitted  to  vaccination,  became 
affected  in  about  the  same  proportion,  and  to  the  same 
extent,  as  others  not  inoculated. 


23.  Analogous  Pocks  in  other  Animals. — In  the 
Camel. — Although  various  animals  have  at  times  been 
stated  to  be  liable  to  eruptive  fevers  which  have  been 
considered  to  have  some  analogy  to  human  variola  on 
the  one  hand,  or  to  cow-pox  on  the  other,  we  have  no 
accounts  respecting  any  of  these  which  are  not  vague 
and  wholly  inconclusive.  The  most  probable  instance 
of  any  animal  being  subject  to  an  affection  like  the 
cow-pox  is  the  occurrence,  it  is  said,  among  camels,  in 
the  province  of  Lus,  in  Beloochistan,  of  a  disease 
which  the  natives  call  "  Photoshootur,"  or  the  small- 
pox of  camels.  This  disease  is  affirmed  to  be  commu- 
nicable to  the  camel-milkers,  and  to  protect  them  from 
small-pox.  No  attempt  is  made  by  them  to  propagate 
it  by  inoculation.* 

24.  Vaccination  and  Variolation  of  other  Animals. 
— The  insertion  of  vaccine  lymph  on  dogs  produces 
an  effect  much  more  resembling  regular  vaccine  than 
the  like  experiment  on  sheep ;  but,  according  to  Sacco, 
the  course  is  shorter  than  in  the  human  subject,  and 
there  is  no  areola.  The  lymph  obtainable  from  the 
vesicles  produced  in  the  dog  may,  it  is  said,  be  con- 
tinued from  animal  to  animal,  and  even  reinoculated 
in  the  human  subject,  with  the  result  of  reproducing 

*  Indian  Journal  of  Medical  Science,  Oct.  1839. 


OF  POCKS  IN  OTHER  ANIMALS.  55 

genuine  vaccination.*  Jenner  at  first  believed  that 
dogs  might  be  constitutionally  affected  by  vaccinia, 
and  thereby  protected  against  that  infectious  disease, 
the  distemper ;  but  he  apparently  did  not  remain  long 
in  this  belief,  for,  in  his  account  of  the  dog  distemper 
in  1809, f  he  makes  no  allusion  whatever  to  the  em- 
ployment of  vaccination.  Inoculation  of  dogs  with 
the  matter  of  variola  by  MM.  Reynal  and  Renault 
produced  no  result; J  and  I  do  not  in  the  least  know 
what  value  is  to  be  attached  to  a  statement  that  Vi- 
borg  performed  a  successful  inoculation  of  this  kind.§ 
The  goat  is  said,  on  the  authority  of  M.  Valentin,  of 
Nancy,  ||  of  M.  Husson,  and  more  recently  of  MM. 
Mathieu  and  Auzias  Turenne,  to  be  susceptible  of  vac- 
cination; and  M.  Chauveau  and  his  colleagues  pro- 
duced on  this  animal,  in  two  experiments,  umbilicated 
vesicles,  but  of  a  very  modified  kind.^[  The  accounts 
we  have  of  inoculations  performed  with  vaccine  or 
with  variolous  lymph  on  various  other  kinds  of  ani- 
mals either  record  failure,  or  give  results  too  vaguely 
and  inconclusively  to  render  a  detail  of  them  of  any 
interest. 

*  Baron's  Life  of  Jenner,  vol.  i.  p.  243 ;  and  Sacco,  as  quoted 
in  King's  Treatise,  p.  941. 

■J-  Medico-Chirurgical  Transactions,  vol.  i. 

I  Bulletin  de  l'Academie,  tome  xxix.  p.  334. 

g  Baron's  Life  of  Jenner,  vol.  i.  p.  216. 

||  Ibid.,  p.  243. 

^  Vaccine  etVariole  :  Rapport,  etc.  (op.  cit.).  M.  Chauveau 
and  his  colleagues  speak  of  the  goat  as  being  an  animal  to 
which  Jenner  had  communicated  the  vaccine,  but  this  is  a 
mistake. 


56  n AND  BOOK  OF   VACCINATION. 


CHAPTER    IV. 

OF   THE   RELATION   OP   COW-POX   AND   HORSE-POX   TO 
HUMAN    VARIOLA. 

25.  Jenner's  views  on  this  subject. — It  was  one  of 
Jenner's  fundamental  doctrines,  that  the  cow-pox  and 
the  horse-pox  (or  grease,  as  he  at  first  regarded  it) 
were  products  of  the  same  virus  as  produced  the  small- 
pox in  man.  The  disease  in  the  horse  was  considered 
by  him  to  be  the  parent  disease ;  that  in  the  cow  and 
in  man  as  derived  diseases.  The  malignancy  and  pe- 
culiarly infectious  character  of  human  variola  were 
not,  in  his  view,  any  essential  part  of  the  effects  pro- 
ducible by  the  variolous  poison  on  the  human  consti- 
tution, but  were  properties  at  first  accidentally  super- 
added, and,  when  once  acquired,  capable  of  propagation. 
"  May  it  not  be  reasonably  conjectured  that  the  source 
of  the  small-pox  is  morbid  matter  of  a  peculiar  kind, 
generated  by  a  disease  in  the  horse,  and  that  accidental 
circumstances  may  have  again  and  again  arisen,  still 
working  new  changes  upon  it,  until  it  has  acquired  the 
contagious  and  malignant  form  under  which  we  now 
commonly  see  it  making  its  devastations  among  us?"* 
If  man  would  only  go  back  to  the  horse  or  cow,  and 
take  his  small-pox  direct  from  them,  he  might  have  it 
apart  from   these   unessential   malignant   characters. 

*  Inquiry  into  the  Causes  and  Effects  of  the  Variola)  Vac- 
cinae, p.  52. 


RELATION  TO  HUMAN   VARIOLA.  57 

And  a  person  having,  accidentally  or  designedly,  con- 
tracted cow-pox,  was  held  by  Jenner  to  be  safe  from 
sn^all-pox,  not  because  he  had  gone  through  some  pecu- 
liar disease  which  stood  in  mysterious  antagonism  to 
small-pox,  but  simply  because  he  had  actually  gone 
through  small-pox  itself.  So  much  of  these  specula- 
tions as  ascribes  the  origin  of  human  and  vaccine  va- 
riola to  the  horse  has  received  less  attention  probably 
than  it  deserved,  and  has  certainly  had  little  accept- 
ance :  but  the  truth  of  the  more  essential  part  of  the 
teaching — the  common  origin  of  the  Variolar  Vaccinae, 
Variolas  Equinae,  and  Variolae  Humanae,  from  one  spe- 
cific infection — has  been  established  by  conclusive  ex- 
periments. 

26.  Inoculation  of  Cattle  with  Small-pox.— Jenner 
himself  did  not  perform  any  inoculations  of  cattle  with 
the  lymph  of  human  variola.  But  as  early  as  1801, 
Gassner,  of  Gunsburg,  by  inoculating  eleven  cows  with 
small-pox  matter,  produced  on  one  of  them  vesicles 
from  which  he  was  able  to  inoculate  four  children : 
these  children  developed  the  ordinary  phenomena  of 
vaccination,  and,  with  lymph  from  them,  seventeen 
other  children  were  similarly  infected.*  Thus  it  hap- 
pened that  in  the  same  year — the  third  after  the  pro- 
mulgation of  Jenner's  discovery — Loy  demonstrated 
the  production  of  the  vaccine  disease  in  the  cow  by 
inoculation  from  Variolae  Equinae  (§  14),  and  Gassner, 
by  inoculation  from  human  small-pox.  But  the  pro- 
duction of  vaccine  in  the  cow  by  small-pox  inoculation 
is  a  matter  of  very  considerable  difficulty :  for  one  case 
in  which  the  inoculation  succeeds,  it  will  fail  in  at  least 

*  Henke's  Zeitschrift  Ergiinzungs,  heft  xxx.  p.  67. 
6 


58  HANDBOOK  OF   VACCINATION. 

a  dozen.  And  as  Gassner's  experiments,  somehow  or 
other,  were  not  very  widely  known,  while  other  experi- 
ments made  about  the  same  time  in  England  and  else- 
where failed,  Jenner's  doctrine  was  far  from  being  uni- 
versally received.  Beyond  a  mere  general,  though  no 
doubt  well-founded,  statement  made  by  Dr.  McMichael 
to  the  Royal  College  of  Physicians,  in  1828,  that  in 
Egypt  it  had  been  discovered  by  some  medical  men 
that  fine  active  vaccine  virus  might  be  produced  by 
inoculating  the  cow  with  small-pox  from  the  human 
body,  and  that  several  children  had  been  vaccinated 
with  complete  success  with  the  lymph  thus  generated,* 
there  is  no  account  of  any  further  experiments  till 
1830.  In  that  year  Dr.  Sonderland,  of  Barmen,  man- 
aged, he  tells  us,  to  infect  cows  with  the  contagion  of 
variola,  by  enveloping  them  in  blankets  taken  from  the 
bed  of  a  patient  who  had  died  of  small-pox,  and  by 
hanging  such  blankets  up  around  the  head  of  the  ani- 
mal, so  that  it  must  breathe  the  effluvia  arising  from 
them.  And  the  result  was,  that  in  a  few  days  the  cows 
manifested  the  symptoms  of  cow-pox,  and  lymph  taken 
from  them  produced  genuine  vaccine  vesicles  in  the 
human  subject,  f  Some  remarkable  circumstances  will 
presently  be  stated  (§  21),  tending  strongly  to  show 
that  vaccinia  may  be  produced  in  cows  by  the  action 
of  variolous  effluvia.  All  the  attempts,  however,  which 
were  made  to  infect  cows  directly  by  repetition  of  Son- 
derland's  experiments — as  in  England,  by  Mr.  Ceely,| 

*  Keport  of  the  Vaccination  Section  of  Prov.  Med.  and  Surg. 
Assoc,  1839,  p.  24. 

f  Hufeland's  Journal,  Jan.  1831. 

%  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  380. 


RELATION  TO   HUMAN   VARIOLA.  59 

in  India,  by  Mr.  Macpherson  and  by  Mr.  Lamb,*  and 
on  the  Continent  at  the  Veterinary  School  at  Alfort,  at 
Berlin,  Weimar,  Bergen,  Dresden,  Kasan,  Utrecht, 
and  Stockholm — were  unsuccessful;  for  although  both 
at  Utrecht  and  Stockholm  a  pustular  or  vesicular  erup- 
tion manifested  itself  on  those  parts  of  the  bodies  of 
the  animals  experimented  on  which  were  in  immediate 
contact  with  the  infected  coverings,  this  was  evidently 
of  a  local  non-specific  cbaracter.f 

But,  in  1836,  Dr.  Thiele,  of  Kasan,  after  several 
fruitless  attempts  to  infect  the  cow  by  inoculation  of 
the  variolous  virus,  at  length  succeeded  in  so  doing, 
and  in  producing  thereby  the  genuine  vaccine  disease ; 
from  this  he  raised  a  stock  of  lymph  for  human  vaccina- 
tions, which,  at  the  time  his  account  was  published, 
had  gone  through  75  transmissions,  and  been  employed 
in  the  vaccination  of  more  than  3000  subjects,  many 
of  whom  had  had  their  security  against  small-pox  tested 
by  inoculation  and  by  the  closest  exposure  to  the  in- 
fection of  that  disease.  Dr.  Thiele,  on  various  occa- 
sions afterward,  succeeded  in  producing  cow-pox  in 
cows  by  variolous  inoculation,  and  he  attributes  much 
of  his  later  success,  after  so  many  early  failures,  to  the 
precautions  he  takes  in  the  selection  of  the  animals,  and 
in  the  mode  of  conducting  the  experiments.     Cows 

*  Trans.  Med.  and  Phys.  Society  of  Calcutta,  vol.  vi.  and 
vol.  viii.  Both  also  tried  variolous  inoculation  on  cows,  with- 
out success. 

f  Hering,  Ueber  Kuhpocken  an  Kuhen,  pp.  9-12.  Hering 
thinks  that  Ketzius,  of  Stockholm,  told  him  that  it  had  hap- 
pened to  Prof.  Billing  to  produce  regular  vaccine  by  inocula- 
ting cows  on  the  udders  with  variolous  matter,  and  that  a 
stock  of  lymph  was  thus  obtained. 


60  HANDBOOK  OF   VACCINATION. 

should  be  selected  from  four  to  six  years  old,  which 
have  recently  calved,  and  if  possible  which  have  white 
or  fair  teats  ;  they  should  be  kept  at  a  uniform  tempera- 
ture (15°  It.);  the  inoculation  should  be  performed  at 
the  base  of  the  udder,  out  of  the  way  of  licking,  the 
udder  being  first  shaven ;  and  the  variolous  lymph 
should  be  in  a  clear  limpid  state.*  Before  Dr.  Thiele's 
experiments  were  known  in  this  country,  Mr.  Ceely  of 
Aylesbury  had  succeeded  (in  February,  1839)  in  in- 
ducing vaccine  vesicles  in  two  sturks  by  inoculation 
with  variolous  lymph,  and  in  thus  establishing  lymph- 
stocks  which  passed  at  once  into  extensive  use,  so  that, 
in  a  few  months,  more  than  2000  children  had  been 
vaccinated  from  them.f  In  many  of  these  subjects  the 
protective  value  of  this  variola-vaccine  lymph  was 
tested  by  variolous  inoculation  by  Mr.  Ceely  himself,  at 
various  periods  after  the  vaccination ;  no  constitutional 
affection  was  produced  thereby  in  any  case,  and  the 
local  results  resembled  in  every  respect  those  recorded 
by  Willan  as  having  attended  the  test  inoculations 
practiced  in  the  early  days  of  vaccination.  |  In  De- 
cember, 1840,  Mr.  Badcock,  at  that  time  residing  at 
Brighton,  without  any  previous  knowledge  of  Mr. 
Ceely 's  experiments,  succeeded  in  variolating  a  cow, 

*  Henke's  Zeitschrift,  1839,  heft  1. 

f  Trans.  Prov.  Med.  and  Surg.  Assoc.,  vol.  viii.  pp.  379- 
402.  The  experiments  were  made  on  this  occasion  on  three 
animals,  and  succeeded  on  two ;  but  Ceely  says  he  has  many 
times  failed  to  variolate  the  cow,  at  different  seasons  and  un- 
der varying  circumstances,  by  precisely  or  pretty  nearly  the 
same  modes  of  operating  as  were  successful  in  these  instances. 
He  gives  most  valuable  hints  to  those  disposed  to  repeat  his 
experiments. 

X  Ibid.,  vol.  x.  p.  262,  etc. 


RELATION  TO  HUMAN   VARIOLA.  61 

and  deriving  therefrom  a  stock  of  genuine  vaccine 
lymph;*  and  he  has  from  1840  to  the  present  time,  by 
inoculation  of  cows  with  the  lymph  of  human  variola, 
raised  stocks  of  vaccine  lymph  for  use  on  no  fewer  than 
thirty-seven  separate  occasions. •}■  The  lymph  thus  ob- 
tained by  him  is  now  largely  employed ;  it  has  been 
supplied  to  many  hundreds  of  practitioners,  and  very 
many  thousands  of  children  have  been  vaccinated  with 
it.  It  is  worthy  of  note,  however,  as  illustrating  the 
difficulty  attendant  on  the  production  of  vaccinia  in  the 
cow  by  variolous  inoculation,  that  these  thirty-seven 
successes  represent  but  7  per  cent,  of  the  experiments 
undertaken  by  Mr.  Badcock;  to  obtain  them,  he  had 
to  perform  between  five  and  six  hundred  variolous  in- 
oculations. In  1852,  Mr.  Ceely's  experiments  were 
repeated  in  America  .by  Dr.  Adams  of  Waltham,  and 
Dr.  Putnam  of  Boston,  who  were  able,  it  is  said,  in 
consequence,  to  "  furnish  the  city  and  neighborhood 
(of  Boston)  with  all  the  vaccine  matter  used  there 
since  that  period.  "J 

*  A  Detail  of  Experiments  confirming  the  Power  of  Cow- 
pox,  etc. 

•j-  It  must  be  distinctly  understood  that  every  one  of  these 
thirty-seven  successful  experiments  was  the  result  of  the  direct 
inoculation  of  the  animal  with  lymph  taken  from  a  human 
■abject  affected  with  variola;  that  no  case  is  included  in  which 
lymph  taken  from  a  cow  that  had  been  variolated  was  used  to 
inoculate  other  cows.  But  such  transfer  wa§  also  on  one  oc- 
casion made  by  Mr.  Badcock,  and  a  supply  of  vaccine  lymph 
thus  obtained. 

\  Boston  (U.  S.)  Daily  Advertise?-,  April  14,  1852,  as  quoted 
by  Simon,— Papers  relating  to  tho  History  and  Practice  of 
Vaccination,  p.  xiv. 

0* 


62  HANDBOOK  OF   VACCINATION. 

27.  Probable  Case  of  Infection  of  Cattle  by  Vario- 
lous Effluvia. — In  1840,  Mr.  Ceely  met  with  a  case  of 
exceeding  interest,  in  which  there  was  good  ground 
for  believing  that  the  vaccine  disease  was  induced  in 
cows  by  variolous  effluvia.  Eight  milch  cows  and 
two  sturks  were  turned  to  graze  during  the  daytime 
in  a  meadow  at  Oakley,  in  the  Vale  of  Aylesbury,  in 
which  the  clothes  and  bedding  of  a  person  who  had 
died  of  malignant  variola  had  previously  been  exposed 
almost  constantly  night  and  day  for  a  week,  and  in 
which  they  were  still  always  exposed  at  night,  and  not 
always  removed  in  the  morning  before  the  readmission 
of  the  animals.  On  one  occasion,  at  least,  the  cows 
were  observed  in  the  midst  of  the  bed-flock,  licking  it 
up.  Within  twelve  or  fourteen  days  of  their  admission 
to  the  meadow,  five  of  the  milch  cows  and  one  sturk 
exhibited  simultaneously,  or  almost  simultaneously, 
well-marked  cow-pox.  It  was  most  clearly  ascertained 
that  the  animals,  which  were  animals  belonging  to  the 
place,  and  had  not  been  brought  in  from  elsewhere, 
were  in  good  health  at  the  time  of  their  admission  to 
the  meadow,  and  that  there  was  no  vaccine  disease  at 
the  time  anywhere  in  the  Vale.  None  of  the  milkers 
had  any  .sores  on  their  hands,  except  what  they  subse- 
quently got  from  these  cows ;  besides,  one  of  the  in- 
fected animals  was  a  sturk.  The  simultaneousness  of 
the  attack  in  all  the  animals  showed  a  common  cause; 
and  it  is  not  in  the  least  probable  that  this  cause  was 
a  sudden  epizootic  outbreak.  For  the  disease,  on  the 
most  minute  and  diligent  inquiry,  was  not  met  with 
elsewhere ;  and  when  cow-pox  occurs  as  an  epizootic, 
its  characteristic  is,  not  an  appearance  all  at  once  in 
many  animals  in  the  same  dairy,  but  an  appearance  of 


RELATION  TO  IIUMAN    VARIOLA.  63 

it  at  the  same  time,  or  about  the  same  time,  on  one 
or  two  animals  in  various  different  farms.  When  on 
any  farm  several  animals  are  attacked,  this  is  found 
always  to  proceed  from  infection  from  the  one  or  two 
primary  cases;  and  Mr.  Ceely  states  that,  in  the  whole 
course  of  his  experience,  he  never  saw  so  many  primary 
cases  together  in  a  dairy  at  one  time,  as  on  this  occa- 
sion. Lastly,  the  period  of  attack — ten  or  twelve  days 
from  the  first  exposure — corresponds  entirely  with  what 
might  be  anticipated  if  the  common  cause  of  the  out- 
break were  variolous  effluvia.* 

28.  Phenomena  of  successful  Variolation  of  Cows. 
— The  phenomena  of  successful  variolation  of  the 
cow,  as  described  by  M.  Thiele,  consist  first  in  the 
development  of  "tubercules"  under  the  skin;  these, 
by  the  fifth  day,  resemble  advancing  vaccine  vesicles ; 
and  from  the  seventh  to  the  ninth  day  they  have  cen- 
tral depression,  and  are  found  to  contain  limpid  lymph. 
From  the  ninth  to  the  eleventh  day  desiccation  sets  in, 
and  a  crust  forms,  which  on  falling  leaves  a  smooth 
cicatrix.  If  from  three  to  six  punctures  have  been 
made,  generally  not  more  than  one  or  two  vesicles  will 
be  found  resulting.  Ceely  states,  with  great  care,  the 
phenomena  exhibited  in  his  successful  cases.  In  one 
of  these,  though  seven  punctures  were  made,  and  four- 
teen points,  charged  half  their  length  with  variolous 
lymph,  were  introduced,  as  well  as  two  setons  inserted 
which  had  been  impregnated  with  small-pox  virus,  no 
phenomena  indicative  of  taking  were  noticed  till  the 
tenth  day,  when  some  of  the  punctures  were  found 
hard  and  elevated,  and  one  had  assumed  the  form  and 

*  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  x.  pp.  211-225. 


64  HANDBOOK  OF   VACCINATION. 

appearance  of  the  vaccine  vesicle ;  it  was  nearly  circu- 
lar, had  an  elevated  margin,  and  a  small  crust  in  the 
depressed  center.  From  this  vesicle  it  was  possible, 
by  pains  and  care,  scantily  to  charge  thirty-eight 
points  in  the  course  of  an  hour,  which  points  were 
afterward  used  to  inoculate  children,  and  produced  in 
them  all  the  phenomena  attending  the  use  of  primary 
cow-lymph.  Two  other  of  the  punctures  in  this  cow 
seemed  to  advance  a  little,  but  no  lymph  formed  in 
them,  and  the  vesicle  above  described  was  the  single 
vesicle  caused  by  variolation.  In  its  progress  and  de- 
cline this  vesicle  followed  exactly  the  course  of  the 
primary  vaccine  vesicle  in  the  cow.* 

In  the  other  ultimately  successful  experiment,  the 
first  attempt  to  inoculate  the  cow,  made  in  the  same 
way,  by  seven  punctures  and  two  setons,  failed ;  and, 
at  the  end  of  a  fortnight,  more  small-pox  virus,  taken 
at  the  seventh  and  eighth  days  of  the  disease,  was 
forced  into  eight  punctures,  "  which  were  deluged  with 
it,  the  punctures  being  afterward  irritated  with  points 
deeply  charged  with  the  same,  which  were  suffered  to 
remain  in  the  punctures."  By  the  fifth  day  there  re- 
sulted from  this  last  inoculation  eight  distinct  papules, 
which  by  the  day  following  had,  each  of  them,  all  the 
appearance  of  the  vaccine  vesicle.  From  one  of  them 
clear  lymph  was  obtained,  with  much  difficulty,  so  as 
scantily  to  charge  thirty-nine  points.  On  the  eighth, 
the  ninth,  and  the  tenth  days,  it  was  found  that  four 
only  of  the  papules  had  become  decided  vesicles,  and 
from  one  or  other  of  these  some  more  lymph  was  taken. 
The  vesicles  were  at  their  fullest  development  on  the 

*  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  382,  seq. 


RELATION  TO  HUMAN    VARIOLA.  65 

tenth  day,  and  the  commencement  of  the  decline  on 
the  eleventh  was  obvious;  the  crusts  fell  about  the 
twenty -fourth  day.*  When  the  lymph  generated  by 
these  experiments  was  employed  on  the  human  sub- 
ject, it  was  found  to  produce  exactly  the  same  phenom- 
ena as  are  developed  by  primary  cow-lymph  ;f  and  it 
is  most  important  to  note,  for  reasons  that  will  imme- 
diately appear,  that  though  on  some  of  the  subjects  in 
whom  this  lymph  was  used,  eruptions  of  roseola  and 
lichen  were  seen,  as  is  frequently  the  case  when  pri- 
mary cow-lymph  has  been- used,  no  eruption  with  the 
slightest  approach  to  varioloid  character  was  observed. 
It  is  further  very  material  to  note  that  these  experi- 
ments were  made  with  every  care  to  guard  against 
any  possible  source  of  fallacy.  The  small-pox  virus 
used  was  collected  by  Ceely  himself:  every  point  and 
tube  used  was  perfectly  new.  The  phenomena  were 
watched  by  himself  and  others  day  by  day;  and  in 
collecting  the  products  of  the  inoculation,  which  was 
also  done  by  himself  in  the  presence  of  others,  every 
precaution  was  employed  so  that  no  possible  mistake 
could  arise.  J 

29.  Change  which  the  Variolus  Virus  undergoes  in 
passing  through  the  Cow. — But  though  cow-pox  in 
the  cow  and  human  variola  have  been  thus  clearly 
proved  to  arise  from  the  same  infection,  this  infection 


*  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  385. 

f  See  description  of  the  effects  produced  on  the  human  sub- 
ject by  variola-vaccine  lymph, in  chap.  v.  \  44. 

J  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  390.  The 
reader  must  himself  consult  this  admirable  memoir  fully  to 
appreciate  the  care  with  which  the  whole  investigation  was 
conducted. 


66  HANDBOOK  OF   VACCINATION. 

in  passing  through  the  cow  undergoes  such  alteration 
as  deprives  it  of  all  malignity  and  of  all  power  of  prop- 
agating itself  among  the  human  species  by  effluvia. 
The  small- pox  of  man  conveyed  to  the  cow  produces 
cow-pox ;  but  the  cow-pox  thus  induced,  retransferred 
to  man,  is  as  incapable  as  the  natural  cow-pox  itself 
of  producing  infectious  small-pox.  Many  tens  of  thou- 
sands of  persons  in  England  have  been  vaccinated  by 
various  hands  (see  ante,  §  2G)  with  lymph  thus  gener- 
ated— variola-vaccine  lymph,  as  it  is  called.  Mr.  Bad- 
cock  alone  has  performed  upwards  of  20,000  vaccina- 
tions with  it.  So  that  the  properties  of  the  lymph  are 
established  on  a  scale  far  too  considerable  for  question. 
30.  Experiments  of  M.  Chauveau,  etc. — Probably 
the  experiments  of  Thiele  and  Ceely  have  been  known 
chiefly  in  France  through  the  singularly  inaccurate 
and  imperfect  account  of  them  given  in  the  classical 
work  of  Bousquet,*  and  probably  also  the  confirmation 
they  have  received  from  the  repeated  experiments  of 

*  The  fourteen  pages  devoted  by  M.  Bousquet  to  the  subject 
of  the  renewal  of  vaccine  <cen  inoculant  la  varioleala  vache" 
(Nouveau  Traite,  pp.  437-451),  besides  many  inaccuracies 
with  regard  to  Thiele's  and  Ceely's  experiments,  contain  a 
piece  of  intelligence  which  sounds  strange  and  amusing  to 
English  ears.  M.  Bousquet  says  that,  in  England,  when 
children  were  vaccinated  with  Ceely's  variola-vaccine  lymph, 
"les  premiers  n'ont  eu  qu'une  eruption  locale;  mais,  en  pour- 
suivant  les  experiences,  il  s'en  est  trouve  qui  ont  eu  une  variole 
complete,  tellement  que  l'autorite  a  fait  defense  de  communi- 
quer  ce  virus,  et  a  puni  une  infraction  de  300  fr.  d'amende." 
Perhaps  this  extraordinary  statement,  for  which  it  need 
scarcely  be  said  there  is  not  the  slightest  foundation,  may 
have  helped  to  mislead  M.  Chauveau  and  his  colleagues. 
(Vide  postea.) 


RELATION  TO   HUMAN   VARIOLA.  6T 

Mr.  Badcock  is  there  quite  unknown ;  but  certain  it  is 
that  the  variolous  origin  of  cow-pox,  which  has  been 
completely  accepted  in  this  country  for  the  last  quar- 
ter of  a  century  and  more,  has^  remained  in  France 
one  of  the  open  questions.  And  now,  some  recent  ex- 
periments which  have  been  made  at  Lyons  are  said  to 
have  shown  that  it  is  a  delusion  to  suppose  that  the 
inoculation  of  cows  with  variola  has  ever  produced 
cow-pox,  for  in  fact  it  produces  in  that  animal  real 
small-pox,  and  nothing  else.  This  statement,  how- 
ever, is  not  quite  new.  Once  before,  at  the  Veterinary 
School  at  Berlin,  inoculation  of  the  cow  with  variolous 
lymph  was  performed,  and  "pustules,"  it  is  said,  pro- 
duced, which,  when  inoculated  back  on  the  human 
subject,  were  found  to  reproduce  small-pox.  No  de- 
tails were  given,  and  the  value  of  the  experiment  can- 
not, therefore,  be  determined.*  A  similar  result  is 
said  to  have  been  obtained  at  Boston  (U.  S.)  in  1860.f 
But  the  more  recent  experiments  leading  to  the  same 
conclusion,  which  were  performed  by  M.  Chauveau,  of 
Lyons,  with  the  assistance  of  MM.  Viennois  and  Mey- 
net,  are  stated  in  full  detail  in  a  most  interesting  me- 
moir published  by  them  on  this  subject  ;|  and  as  these 
experiments  satisfied  a  committee  of  the  AcadCmie  des 

*  Verheyen,  Momoire.sur  la  Vaccine  primitive,  in  Mem. 
de  l'Acad.  ltoyale  de  Medeeine  de  Belgique,  tome  i.  But 
Verheyen  gives  the  statement  at  second-hand,  and  refers  to 
Viborg,  Saviml.  B.  iii.  S.  112. 

f  Boston  Med.  and  Surg.  Journ.,  Feb.  23,  1860,  as  quoted 
in  the  "Year-Book  of  Medicine  for  1860."  (New.  Syd.  Soc.) 

%  Vaccine  et  Variolo  :  Rapport  par  MM.  Chauveau,  Vien- 
nois, et  Meynet,  in  Memoires  et  Comptes  Rendus  de  la  Soc. 
des  Sc.  Med.  de  Lyon,  tome  v. 


68  HANDBOOK  OF   VACCINATION. 

Sciences  that  a  distinct  small-pox  disease  may  be  in- 
duced in  the  cow  or  horse  by  variolous  inoculation,  as 
cow-pox  is  induced  in  them  by  vaccine  inoculation, 
the  small-pox  virus  in  its  transit  through  these  animals 
being  incapable  of  conversion  into  vaccine,  they  de- 
mand our  most  attentive  consideration.  According  to 
the  statements  of  M.  Chauveau  and  his  colleagues,  in- 
oculation of  cows  or  of  horses  with  the  lymph  of 
human  variola  gives  rise  to  no  general  symptoms  of 
any  kind,  but  is  invariably  followed  by  a  local  erup- 
tion of  papules.  These  papules  in  the  cow  are  described 
as  being  from  two  to  four  millimetres  only  in  diameter, 
scarcely  projecting  above  the  surface,  slightly  conical, 
and  with  the  puncture  of  inoculation  visible  at  the 
center;  they  are  at  their  fullest  development  by  the 
fifth  day,  and  are  quite  gone  by  the  twelfth,  leaving  an 
extremely  small  blackish  crust  or  scale  at  the  point  of 
puncture ;  at  no  period  of  their  course  do  they  exhibit 
any  tendency  whatever  to  secretion.  The  authors 
state  that  the  greater  number  of  persons,  competent  to 
form  a  judgment,  to  whom  these  papules  were  shown, 
regarded  them  as  the  simple  result  of  inflammatory 
action  round  an  inoculated  point,  and  as  indicative  of 
no  specific  infection ;  they  themselves,  however,  con- 
sider them  to  be  a  true  variolous  eruption,  which,  it  is 
admitted,  is  "si  peu  accuse  dans  un  grand  nombre  de 
cas,  qu'il  faut  une  certaine  habitude  pour  en  constater 
la  presence."  There  is,  in  fact,  so  little  of  definite 
character  about  this  eruption,  that  though  the  authors 
can  themselves  detect  it,  they  would  find  it  difficult, 
they  say,  to  point  out  to  others  the  exact  characters 
which  should  distinguish  a  successful  inoculation  from 
a  failure.     In  the  horse,  papulation  was  found,  in  the 


RELATION  TO  HUMAN   VARIOLA.  69 

three  experimental  inoculations  that  were  made,  to  be 
much  more  evident  than  in  the  cow;  the  papules  were 
conical,  reddish,  and  tender;  they  ran  a  course  exactly 
like  that  of  the  papules  in  the  cow,  and  disappeared 
("  sans  qu'on  ait  constate  la  moindre  tendance  a  la  se- 
cretion") by  gradual  absorption  and  desquamation  of 
the  epidermis  over  their  surface.  By  removing  a  num- 
ber of  these  papules  from  some  cows,  and  scraping 
well  their  inner  surface,  or  by  removing  the  central 
scales  from  some  of  the  papules  of  the  horse,  and 
squeezing  the  little  cavities  then  laid  bare,  excessively 
minute  quantities  of  a  serous  liquid  were  got,  which, 
when  inoculated  from  cow  to  cow,  or  from  horse  to 
horse,  or  from  horse  to  cow,  produced  much  slighter 
local  effects  than  the  foregoing,  so  that  (except  in  one 
case,  which  unfortunately  could  not  be  followed  out)  it 
was  uncertain,  even  to  the  authors,  whether  the  inocu- 
lation had  taken  or  not,  but  which  when  inoculated  on 
the  human  subject  reproduced  variola.  With  serosity 
taken  from  one  of  the  cows  and  one  of  the  horses,  local 
vesicles,  followed  by  general  varioliform  eruption,  were 
in  fact  produced  on  three  children,  and  from  these  chil- 
dren other  variolous  inoculations  were  performed.* 
These  results  are  regarded  by  the  experimenters  as 

*  "With  regard  to  some  of  these  cases,  however,  more  par- 
ticular information  would  have  heen  very  desirable  as  to  the 
opportunities  the  children  had  of  contracting  variola  by  in- 
fection in  the  usual  way.  It  is  clear  there  was  small-pox  at 
Lyons  at  the  time ;  and  I  think  it  not  improbable  that  in 
some  of  the  later  inoculations,  which  were  attended  with 
dangerous  symptoms,  the  subjects  of  inoculation  might  already 
have  taken  infection  in  the  natural  way.  Refer  to  the  con- 
cluding note  of  this  chapter. 

7 


70  HANDBOOK  OF  VACCINATION. 

showing  that  the  inoculation  of  variola  on  horses  and 
cows  produces  a  true  variolous  infection,  and  that  the 
organism  of  these  animals  is  therefore  incapable  of 
transforming  variola  into  vaccine.  But  they  do  not 
appear  to  me  to  lead  at  all  necessarily  to  the  conclusions 
thus  drawn.  The  local  effects  produced  by  these  inoc- 
ulations were  not  in  any  respect  greater  than  those 
produced  by  Ceely  in  cases  which  he  regarded  as  fail- 
ures,* nor  than  in  cases  which  the  authors  themselves 
at  first  put  aside  as  failures,  nor  than  the  results  which 
followed  some  variolous  inoculations  of  horses  (two) 
performed  in  1863  by  MM.  Le  Blanc  and  De  Paul, 
which  were  regarded  by  them  as  unsuccessful. \  And  it 
is  not  in  the  least  improbable  that  if  Mr.  Ceely,  or  MM. 
Le  Blanc  and  De  Paul,  had,  in  the  cases  they  describe, 
dealt  with  the  tumid  papules  that  arose  as  M.  Chauveau 
and  his  colleagues  did,  J  they  might  have  got  from  them 
the  same  stuff  they  had  put  in,  stuff  which  had  under- 
gone no  sort  of  transformation  whatever,  but  which  had 
lain  where  it  was  put,  as  in  a  pouch,  quite  inert,  giving 
rise  only  to  local  irritation  without  inducing  any  sort 
of  general  affection  or  disease.  M.  Chauveau  and  his 
colleagues  are  indeed  fully  aware  that,  unless  they  can 

*  Ceely,  Trans.  Prov.  Med.  and  Surg.  Assoc.,  vol.  viii.  pp. 
385,  387. 

f  Bulletin  de  l'Acad.,  tome  xxix.  p.  370. 

\  No  doubt,  by  removing  the  papules  as  they  did,  these  ex- 
perimenters may  have  missed  a  chance  of  a  really  successful 
inoculation.  In  Mr.  Ceely's  first  successful  experiment  (op. 
cit.  p.  382)  the  local  phenomena  on  the  fifth  day  were  fully 
as  much  developed  as  any  described  in  the  Lyons  memoir,  by 
the  ninth  day  he  had  begun  to  despair  of  the  inoculation 
taking,  and  it  was  not  till  the  tenth  that  a  vaccine  vesicle  was 
developed.    (See  account  in  text,  \  28.) 


RELATION  TO   HUMAN   VARIOLA.  fl 

prove  that  a  disease,  a  constitutional  affection,  was  im- 
parted to  the  animals  by  variolous  inoculation,  their 
experiments  will  remain  inconclusive;  and  they  en- 
deavor to  show  that  horses  and  cows  that  have  under- 
gone what  they  consider  as  successful  variolous  inocu- 
lation (and  all  their  inoculations  of  these  animals  with 
the  matter  of  natural  human  variola  were  successful),* 
became  insusceptible  of  vaccination.  But  their  exper- 
iments are  far  from  establishing  this :  in  ten  cows  and 
one  horse  which  had  had  the  so-called  variolous  erup- 
tion, vaccination  took  completely  on  one,  imperfectly  on 
three,  and  on  the  remainder  failed.  It  is  quite  true 
that  the  same  vaccine  lymph  with  which  these  experi- 
ments were  made,  used  on  three  animals  on  which  no 
variolous  lymph  had  been  inserted,  took  effect  in  all, 
and  that,  generally,  the  vaccination  of  cows  was  found 
by  the  experimenters  very  surely  to  take  effect;  but  it  is 
a  well-known  fact  that  the  degree  to  which  cows  are  sus- 
ceptible of  the  vaccine  inoculation,  independently  of  any 
variolous  or  other  experiment  having  been  tried  upon 

*  Considering  the  difficulties  always  more  or  less  attending 
the  transplantation  of  the  exanthematous  diseases  of  one 
species  of  animal  to  animals  of  another  species,  the  uniform 
success  of  these  attempts  is  very  remarkable,  and  in  itself  sug- 
gestive of  error.  Of  twelve  cows  and  three  horses,  in  which 
inoculation  with  variola  was  tried,  there  was  not  one  failure ; 
and  although  the  results  on  five  cows  (they  do  not  remember 
the  number  exactly,  but  are  sure  it  was  at  least  five)  inocu- 
lated at  an  antecedent  period  had  been  regarded  at  the  time 
as  unsuccessful,  this  judgment  was  afterward  recalled  by  the 
experimenters,  and  ascribed  to  their  not  having  then  made 
out  the  real  characters  of  the  variolous  eruption  in  the  cow. 
So  that  the  inoculation,  according  to  this  account,  took  effect 
on  the  whole  twenty  animals  on  which  it  was  tried. 


72  HANDBOOK  OF    VACCINATION. 

them,  is  very  various  (see  §  12,  c),  and  the  test  would 
have  to  be  applied  to  a  much  larger  extent,  and  under 
other  conditions,*  than  has  yet  been  done,  to  justify  such 
sweeping  conclusions.  When  M.  Bouley  inoculated  a 
cow  with  variola  with  the  same  results  as  M.  Chauveau 
obtained,  and  vaccinated  it  afterward,  he  produced  reg- 

*  Especially  it  would  be  desirable  that  the  vaccination 
should  in  some  cases  be  tried  some  time  after  the  variolous  in- 
oculation, and  not,  as  in  all  these  cases,  immediately  after  it. 
It  has  been  said  (I  know  not  with  what  truth)  that  the  vac- 
cination of  sheep,  which  only  produces,  as  has  been  shown,  a 
local  affection,  and  no  disease  which  stands  in  the  place  of 
sheep-pox,  will  yet  for  a  few  weeks  render  the  animals  insus- 
ceptible of  sheep-pox.  In  reference  to  this,  Dr.  W.  Budd  ob- 
serves: "There  is,  indeed,  evidence  to  render  it  probable 
that,  for  some  weeks  after  vaccination,  sheep  are  somewhat 
less  prone  to  take  clavelee — sheep-pox — in  the  natural  way ; 
but  there  is  clearly  nothing  specific  in  the  protecting  influence. 
Louis  has  remarked  that  typhoid  fever  hardly  evej  occurs  in 
persons  who  may  at  the  time  be  the  subject  of  any  other  mor- 
bid disturbance.  The  two  facts  are  probably  of  the  same  or- 
der." I  do  not  myself,  however,  lay  much  stress  on  this.  I 
simply  think  that  a  great  deal  too  much  is  made  of  half  a 
dozen  cows  not  taking  cow-pox  when  inoculated  with  it,  and 
I  confess  I  have  not  much  doubt  that,  if  the  vaccination  were 
repeated  on  those  animals,  it  would  be  found  to  take  effect  on 
some  of  them — unless,  indeed,  they  were  animals  which  had 
already  had  cow-pox  naturally  or  otherwise.  Four  attempts 
to  produce  the  variolous  eruption  on  animals  of  the  ox  and 
horse  tribe,  which  had  previously  had  cow-pox  or  horse-pox, 
are  said  to  have  failed,  but  the  account  is  very  unsatisfactory. 
It  is  quite  clear  that  some  local  effect  was  produced,  and  it  is 
with  reference  to  these  experiments  on  cows  that  M.  Chauveau 
and  his  colleagues  make  the  observation,  cited  before  in  the 
text,  that  they  find  it  difficult  to  point  out  to  others  the  differ- 
ence between  failure  and  success. 


RELATION  TO  IIUMAN   VARIOLA.  73 

ular  cow-pox;  and  Ceely  informs  me  that  in  his  vario- 
lous experiments  on  cattle  he  constantly  produced  the 
phenomena  described  by  M.  Chauveau,  and  found  subse 
quent  vaccination  of  these  animals,  in  the  great  majority 
of  cases,  successful.  Lastly,  the  experimenters  of  Lyons, 
who  do  not  appear  to  have  seen  Ceely's  original  me- 
moir,* do  not  in  the  least  dispute  his  account  of  the 
results  he  met  with;  only  what  he  mistook  for  cow- 
pox  vesicles  on  the  cow  was  the  variolous  eruption ; 
and  what  he  produced  on  children  with  lymph  taken 
from  these  vesicles — the  effects  he  describes  with  such 
singular  care  and  minuteness — were  not,  as  he  imagined, 
cow-pox  at  all,  but  simply  inoculated  small-pox  !  The 
hundreds  of  practitioners  who  in  England  have  for 
nearly  thirty  years  been  using  Ceely's  or  Badcock's 
lymph,  must  learn  with  extreme  surprise  that  all  this 
time  they  have  not  been  vaccinating,  as  they  supposed, 
but  actually  unconsciously  variolating  their  patients  1 
— that  they  have  in  fact  been  making  their  patients  so 

*  They  state  that  they  have  not  seen  "the  plates,"  and  the 
memoir  has  not  been  published  in  English  apart  from  them ; 
they  are  also  to  be  found  in  the  only  complete  foreign  trans- 
lation with  which  I  am  acquainted,  viz.,  that  of  Dr.  Heim,  of 
Ludwigsburg,  though,  it  must  be  confessed,  sadly  spoilt  in 
the  coloring  they  underwent  in  Germany.  There  may,  how- 
ever, be  some  complete  translation  of  the  memoir  with  which 
I  am  not  acquainted.  A  sight  of  the  plates  would  apparently 
be  of  little  consequence  to  the  Lyonnese  experimenters,  be- 
cause, if  these  should  show  any  vaccine  vesicle  as  the  result 
of  the  variolous  inoculation,  it  would  only,  they  say,  prove 
that  the  draughtsman  did  not  know  what  he  was  about !  It 
would  at  all  events  have  shown  them  that  their  own  local  re- 
sults on  cattle  were  quite  well  known  in  this  country  twenty- 
live  years  before. 

7* 


74  HANDBOOK  OF   VACCINATION. 

many  foci  of  variolous  infection!*  It  seems  difficult 
to  treat  as  serious  this  hypothetical  suggestion  of  M. 
Chauveau. 

31.  Cattle  not  shown  to  be  subject  to  any  other 
Variolous  Affection  than  Cow-pox. — It  has  been  ad- 
vanced by  some  distinguished  writers — the  late  Dr. 
Baron,  the  friend  and  biographer  of  Jenner,  held 
strongly  this  opinion — that  cattle  are  subject  to  an 
epidemic  small-pox  of  their  own;  probably,  they 
thought,  a  malignant  variety  of  the  disease  known  to 
us  as  cow-pox,  but  differing  from  the  cow-pox  as  we 
see  it,  just  as  in  the  human  subject  a  severe  case  of 
natural  small-pox  might  differ  from  an  inoculated  case 
of  the  same  disease.  But  the  facts  that  have  been  ad- 
vanced appear  insufficient  to  sustain  this  opinion. 
Great  stress  has  been  laid  by  those  who  have  held  it 
on  the  resemblance  which,  in  many  of  its  features,  the 
"cattle  plague"  of  last  century  bore  to  human  small- 
pox, a  resemblance  which  had  struck  various  distin- 
guished observers  of  that  period,  and  from  which  the 
authors  to  whom  I  refer  were  led  to  consider  that  pes- 
tilence as  nothing  else   than   bovine  variola,  f     The 

*  "La  variolation  mediate"  (by  which  is  meant  the  inocu- 
lation of  human  subjects  with  variolous  virus  that  has  passed 
through  the  cow,  but  the  statement  particularly  includes 
Thiele's  and  Ceely's  results)  "  comme  l'inoculation  variolique 
directe,  creerait,  si  elle  se  generalisait,  un  foyer  permanent 
d'infection,  qui  couvrirait  presque  toute  la  surface  du  globe." 
(Vaccine  et  Variole,  etc.,  op.  cit.) 

f  Dr.  Baron  even  regarded  the  cow-pox  discovered  by  Jen- 
ner in  £he  Gloucestershire  dairies  as  the  remains  of  the  vio- 
lent epizootics  of  cattle  plague  which  invaded  England  during 
last  century.  (Report  of  Vaccination  Section  of  Prov.  Med. 
and  Surg.   Assoc,  1839,   p.   12.)      Cheshire  was,  of  all   the 


RELATION  TO  HUMAN   VARIOLA.  ?5 

same  opinion,  it  will  be  remembered,  obtained  consider- 
able acceptance  for  a  time  respecting  the  cattle  plague 
which  recently  made  such  severe  havoc  among  the 
herds  of  Great  Britain.  Bift  I  believe  I  am  right  in 
stating  it  to  be  now  universally  accepted  that  both 
these  plagues — the  one  of  last  century  and  the  one 
with  which  we  have  been  lately  visited — are  one  and 
the  same  disease,  that  which  has  been  long  known 
abroad  as  Rinderpest  or  Steppemurrain ;  a  disease 
which,  in  its  course  and  symptoms,  has  no  doubt  points 
of  analogy  with  small-pox,  but  which  stands  in  no 
causal  relation  to  it.  Each  has  its  own  distinct  infec- 
tion.* 

In  support  of  this  opinion,  reference  has  also  been 
made  to  a  disease  said  to  affect  cattle  in  India,  to 
which  the  natives  give  the  same  name  which  they 
apply  to  small-pox  in  human-kind,  calling  it  Bussunt, 
Mhata,  or  Gotee.f  To  this  similarity  of  name  no  im- 
portance whatever  is  to  be  attached,  for  the  term,  so 
far  as  it  is  applied  to  cattle,  is  not  limited  to  one  disease 
in  particular,  but  includes  a  number  of  diseases,  some 
of  which,  so  far  from  being  analogous  to  small-pox,  are 
not   attended  with   any  sort  of  eruption. %     Nor  are 

counties  of  England,  the  one  that  suffered  most  from  cattle 
plague  during  last  century;  but  we  have  Dr.  Percival's  au- 
thority that  the  covupox  was  unknown  there,  and  yet  it  is  not 
less  a  dairy  county  than  Gloucestershire,  and  the  office  of 
milking  is  performed  also  by  men  and  maid-servants  indis- 
criminately. (Letter  from  Dr.  Percival  to  Dr.  Jenner,  Baron's 
Life  of  Jenner,  vol.  i.  p.  158.) 

*  See  Third  Report  of  the  Commissioners  appointed  to  in- 
quire into  the  Origin,  Nature,  etc.  of  the  Cattle  Plague. 

f  Rep.  of  Vaccination  Section,  etc.  (op.  cit.),  p.  17. 

X  Duncan  Stewart's  Report  on  Small-pox  in  Calcutta  (1844), 
pp.  84,  85. 


76  HANDBOOK  OF   VACCINATION. 

those  forms  of  Gotee  which  are  attended  with  eruption 
regarded  by  the  natives  as  in  any  degree  infectious  to 
mankind ;  no  fear  of  contracting  sores  from  handling 
affected  animals  being  entertained  by  them.  From  some 
kind  of  Gotee,  cow-pox  is  said  to  have  been  propagated 
to  the  human  subject,  in  1832,  by  Mr.  Macpherson, 
who  was  then  the  superintendent  of  vaccination  at 
Moorshedabad.*  The  disease  which  at  that  time  pre- 
vailed among  the  cattle  in  that  district  appears,  by  his 
description  of  it,  to  have  been  very  like  rinderpest,  the 
analogy  to  small-pox  consisting  in  its  being  attended 
with  what  were  called  pustules  all  over  the  body,  term- 
inating in  ulceration.  All  the  cattle  in  the  neighbor- 
hood became  affected,  "and  among  others"  (I  now 
quote  Mr.  Macpherson's  words)  "two  belonging  to 
one  of  my  own  vaccinators.  I  had  them  covered  with 
blankets,  leaving  merely  the  udder  and  teats  exposed 
to  the  air;  on  the  seventh  day  two  small  pustules  made 
their  appearance  on  the  teats  of  one,  which  dried  up 
on  the  tenth,  and  the  crusts  were  removed  on  the 
twelfth  day."  From  these  crusts  eleven  native  chil- 
dren were  inoculated;  one  of  them  successfully,  a 
vesicle  appearing  on  the  fifth  day  which  continued  to 
increase  till  the  ninth  day,  when  it  had  all  the  charac- 
ters of  true  vaccine ;  the  child  suffered  much  from  fever 
for  four  days.  Two  children  were  vaccinated  from 
this  vesicle  with  complete  success,  the  symptomatic 
fever  being  very  severe ;  from  these  two  children,  five 
others  were  successfully  vaccinated,  and  the  stock  of 
vaccine  thus  established  was  afterward  regularly  con- 
tinued.    Some  of  the   children  vaccinated  with  this 

*  Trans.  Mod.  and  Phys.  Society  of  Calcutta,  vol.  vi. 


RELATION  TO   IIUMAN   VARIOLA.  77 

lymph  were  tested  by  variolous  inoculation  and  by  ex- 
posure to  variolous  infection,  and  found  to  be  secure. 
From  these  facts  it  is  not  to  be  doubted  that  a  case  of 
cow-pox  in  the  cow  had  been  met  with ;  but  what  is  to 
be  doubted  is  that  the  Gotee — the  malignant  disease 
above  referred  to — was  the  source  of  this  infection. 
The  description  of  the  state  of  the  animal  from  which 
the  lymph  was  taken  (which  I  have  fully  quoted)  is, 
it  will  be  remarked,  exceedingly  meager;  there  is  not 
any  account  whatever  of  the  general  symptoms  it  exhib- 
ited,* and  the  eruption,  so  far  from  being  like  that  said 
to  be  prevalent,  viz.,  one  of  pustules  all  over  the  body, 
terminating  in  ulceration,  was  of  a  couple  of  pustules 
(vesicles)  only,  having  exactly  the  character  of  an  or- 
dinary case  of  casual  small-pox.  Other  occurrences  of 
equal,  and  in  some  respects  of  more  remarkable,  inter- 
est took  place  the  year  following  (in  1833),  in  another 
part  of  India,  at  Silhat,  in  Assam,  j"  A  disease  then 
prevailing  there  among  cattle,  which  the  natives  called 
Gotee,  and  which,  like  the  disease  at  Moorshedabad, 
was  attended  with  eruption,  Mr.  Furnell,  a  surgeon, 
made  an  unsuccessful  inoculation  with  some  dry  scabs 
taken  from  the  body  of  one  of  the  animals,  and,  being 
obliged  then  to  leave  for  a  short  time,  requested  another 

*  All  I  think  must  participate  in  the  "frequent  regret"  ex- 
pressed by  Dr.  Duncan  Stewart,  in  whose  official  report  these 
cases  will  be  found,  that  "  information  was  not  given  moro 
fully  regarding  the  appearances  of  the  disease  in  the  cows 
from  which  he  took  the  crusts,  one  of  which  succeeded." 
(Stewart,  op.  cit.  p.  146.) 

f  Trans.  Med.  and  Phys.  Soc.  of  Calcutta,  vol.  vii.  p.  453 
(Mr.  Furnell's  account)  ;  and  vol.  viii.  Appendix,  p.  97,  seq. 
(Mr.  Brown's  account). 


78  HANDBOOK  OF   VACCINATION. 

surgeon,  Mr.  Brown,  to  continue  the  experiments.  Mr. 
Brown's  inoculations  of  four  children  from  similar  scabs 
were  all  successful.  No  account  is  given  of  the  symp- 
toms which  the  animals  said  to  have  Gotee  manifested, 
nor  of  the  state  of  the  particular  cow  from  which  the 
scabs  were  taken,  except  that  it  was  lean  and  ill  con- 
ditioned, and  studded  with  scabs  over  the  back  and  ab- 
domen ;  whence  it  is  evident  that,  in  this  case,  the 
animal  had  a  generalized  eruption  of  some  kind  or  other. 
The  four  children  inoculated  from  the  scabs  had  genuine 
vaccine  vesicles,  with  the  increased  constitutional  dis- 
turbance usual  when  primary  cow-lymph  is  used,  and 
for  several  weeks  the  lymph  was  continued,  with  the 
production,  as  was  believed,  of  only  the  ordinary  effects 
of  vaccine,  although  afterward  there  was  ground  for 
suspecting  that,  on  some  of  the  children  vaccinated 
during  this  period,  an  eruption  of  some  kind  (which 
from  subsequent  events  we  need  have  no  hesitation  in 
calling  modified  small-pox)  had  manifested  itself  after 
the  day  on  which  the  children  had  been  inspected.  At 
length,  however — at  the  end  of  about  two  months  from 
the  introduction  of  this  lymph — the  vaccinations,  as 
they  were  believed  to  have  been,  of  a  particular  day 
resulted  in  unquestionable  small-pox.  Now  as  it  is 
quite  out  of  the  question  that  cow-pox  on  the  human 
subject  should  have  been  transformed  into  small-pox, 
only  one  of  two  explanations  of  these  occurrences  is 
possible :  either  the  disease  conveyed  from  the  animal 
to  the  children  was,  from  the  first,  small-pox ;  or  some 
of  the  native  children  who  had  been  the  subjects  of  the 
vaccinations  of  Mr.  Brown  and  the  native  assistants, 
during  the  two  months  that  elapsed  before  these  oc- 
currences took  place,  had  before  the  day  of  their  vac- 


RELATION  TO  HUMAN  VARIOLA.  ?9 

cination  been  exposed  to  variolous  infection,  and  con- 
tracted variola;  and  from  one  of  these  cases  variola 
had  been  propagated.  It  is  quite  certain  that  the  na- 
tive child  from  whom  the  inoculations  were  performed 
which  resulted  in  undoubted  variola  bad  had  an  erup- 
tion, for  it  was  sent  for  so  soon  as  alarm  was  taken, 
and  there  were  found  "a  few  scabs,  about  twenty,  on 
his  entire  body."  There  can  be,  I  think,  little  hesita- 
tion as  to  which  of  these  explanations  should  be  ac- 
cepted.* I  have  not  been  able  to  find  any  particulars 
of  another  case  referred  to  by  Dr.  Baron  as  having 
given  rise  to  similar  circumstances  in  the  practice  of 
Mr.  Wood,  at  Gowalpara.  For  the  last  thirty  years 
we  have  had  no  further  accounts  of  Gotee  in  India,  in 
connection  with  small-pox.  But  it  would  be  very  in- 
teresting that  further  inquiries  should  be  made  in  that 

*  In  trying  new  lymphs  it  is  very  essential  to  be  on  one's 
guard  against  the  fallacies  that  may  arise  if  the  subjects  on 
whom  they  are  tried  have  been  exposed,  or  are  liable  to  ex- 
posure, to  small-pox  infection.  When,  in  1799,  Woodville 
found  the  natural  cow-pox  in  a  London  dairy  and  commenced 
vaccinating  with  it  at  the  Small-pox  and  Inoculation  Hospi- 
tal, he  was  astonished  to  find  three-fifths  of  his  patients  have 
eruptions  not  to  be  distinguished  from  variola ;  and  for  some 
time  he  held  that  the  vaccine  disease  was  an  eruptive  disease, 
like  inoculated  small-pox,  and,  like  it,  infectious.  Jenner  at 
once  pointed  out  that  a  fallacy  existed — that  the  effects  ob- 
served were  not  the  effects  of  "uncontaminated"  cow-pox,  and 
that  variola  itself  must,  in  some  way  or  other,  have  crept  into 
the  constitution.  When  the  same  lymph  was  sent  to  Berke- 
ley (whore  there  was  at  the  time  no  small-pox),  or  when  it  was 
used  by  Woodville  himself  in  his  large  private  practice,  no 
eruptions  followed.  Woodville  afterward  was  quite  satisfied 
of,  And  admitted,  his  error. 


80  HANDBOOK  OF   VACCINATION. 

country,  not  only  in  reference  to  this  point,  but  for  the 
detection  (and  no  doubt  it  will  be  discovered,  if  care- 
fully looked  for)  of  cow-pox  in  the  form  in  which  it  is 
known  in  Europe  and  in  America,  wherever  it  is  met 
with  as  a  natural  disease. 


CHAPTER  V. 

OP   VACCINIA   OR  COW-POX   IN   THE   HUMAN   SUBJECT. 

32.  Cow-pox  in  the  Human  Subject. — Cow-pox  can 
only  be  communicated  to  the  human  subject  by  inocu- 
lation of  the  specific  virus  of  the  disease ;  it  is  not 
communicable  by  effluvia.  The  inoculation  may  be 
made  directly  from  the  cow  or  horse,  but  is  much  more 
surely  and  conveniently  made  in  the  way  discovered 
by  Jenner,  viz.,  from  a  human  being  who  is  at  the 
time  the  subject  of  the  infection.  The  phenomena  to 
which  cow-pox  inoculation  gives  rise  in  those  to  whom 
the  infection  is  communicated  for  the  first  time,  differ, 
generally,  considerably  from  those  exhibited  by  per- 
sons who  have  already  passed  through  the  disease.  It 
will  be  necessary,  therefore,  in  description,  to  treat 
separately  of  the  course  of  primary  and  of  secondary 
vaccination. 

(A)  COURSE  OF  COW-POX  IN  PERSONS  NOT  PRE- 
VIOUSLY INFECTED  BY  IT. 

33.  Phenomena  and  Course  of  Vaccination. — As 
there  are  certain  points  of  difference  between  the  phe- 


COW-POX  IN  THE  HUMAN  SUBJECT.  81 

nomena  which  ensue  when  the  lymph  used  for  vaccin- 
ating is  taken  from  human  subjects,  and  when  it  is 
taken  direct  from  the  cow,  and  as  vaccination  from  the 
human  subject  is  the  plan  universally,  or  all  but  uni- 
versally, adopted,  I  shall  describe  first  the  course  of 
vaccination  thus  performed,  and  then  notice  such  dif- 
ferences as  are  observed  when  lymph  from  the  cow  is 
employed. 

34.  Usual  Course. — When  vaccine  lymph  taken  on 
the  point  of  a  lancet  is  inserted  by  puncture  on  the  arm 
of  an  infant  who  has  not  before  been  vaccinated,  no 
particular  local  effect  is  noticeable  for  the  first  two 
days;  but,  if  the  vaccination  be  about  to  succeed,  by 
the  end  of  the  second,  or  by  the  third  day,  a  slight 
papular  elevation  is  perceptible ;  and  this,  by  the  fifth 
or  sixth  day,  has  become  a  distinct  vesicle,  of  a  bluish- 
white  color,  with  a  raised  edge,  and  a  peculiar,  central 
cup-like  depression.  This  vesicle,  the  structure  of 
which,  like  that  of  the  cow-pox  vesicle  in  the  cow  (§  6), 
is  cellular,  gradually  enlarges,  and  by  the  eighth  day 
(the  day  week  from  the  insertion  of  the  lymph)  has 
attained  its  highest  perfection.  It  is  then  plump, 
round,  and  more  decidedly  pearl-colored ;  it  is  distended 
with  clear  lymph ;  the  elevation  of  its  margin  and  the 
depression  of  its  center  are  more  marked.  At  this 
date,  or  sometimes  a  few  hours  earlier,  a  ring  of  in- 
flammation, termed  the  areola,  begins  to  form  about  its 
base,  and  the  vesicle  and  areola  together  continue  for 
the  next  two  days  to  spread.  The  areola  is  circular, 
and,  when  fully  developed,  has  a  diameter  of  from  one 
to  two  inches ;  it  is  often  attended  with  considerable 
hardness  and  swelling  of  the  subjacent  connective  tis- 
sue.  The  establishment  of  the  areola  demands  always 

8 


82  HANDBOOK  OF   VACCINATION. 

the  attention  of  the  practitioner  and  student,  as  the 
anatomical  evidence  that  the  cow-pox  has  produced  its 
specific  effect  on  the  constitution.  Other  proofs  of  the 
constitutional  influence  of  the  vaccination  are,  at  this 
period  of  its  course,  generally  afforded  in  the  child's 
restlessness  and  heat  of  skin,  with  (frequently)  derange- 
ment of  the  stomach  and  bowels,  and  with  (sometimes) 
swelling  of  the  axillary  glands.  But  these  general 
symptoms,  though  seldom  altogether  absent,  are  often 
exceedingly  slight;  and  their  absence  (provided  always 
that  the  proper  areola  is  formed)  constitutes  no  reason 
for  doubting  the  protective  influence  of  the  vaccination. 
After  the  tenth  day  the  areola  begins  to  fade,  the  ves- 
icle begins  to  dry  in  the  center,  the  lymph  remaining 
in  it  becomes  opaque  and  concretes,  and,  by  the  four- 
teenth or  fifteenth  day,  a  hard  brown  scab  is  formed. 
The  scab  gradually  contracts,  dries,  and  blackens,  and 
from  the  twentieth  to  the  twenty-fifth  day,  falls  off, 
leaving  a  cicatrix  which  is  commonly  permanent,  and 
which  in  character  is  circular,  somewhat  depressed, 
foveated  or  indented  with  minute  pits,  and  sometimes 
radiated.  A  well-foveated  cicatrix  is,  next  to  having 
watched  the  vaccination  through  its  course,  the  best 
test  we  have  of  the  security  of  the  system  against 
small-pox.  On  comparing  the  course  of  cow-pox  as  it 
manifests  itself  in  the  human  subject  with  its  course  in 
the  cow,  we  find  that  the  phenomena  are  essentially 
alike,  but  that  there  exist,  at  the  same  time,  certain 
points  of  difference.  In  the  human  subject  the  vesicles 
are  fresher,  juicier,  and  more  convex ;  their  appearance 
is  more  exactly  simultaneous ;  they  have  more  uni- 
formly, and  more  essentially  the  central  depression; 
and  the  areola  is  much  broader  and  much  more  marked. 


COW-POX  IN  THE  HUMAN  SUBJECT.  83 

When  the  mode  of  inserting  or  applying  the  lymph 
has  not  been  by  single  puncture,  nor  by  such  abrasion 
of  the  skin  as  would  raise  a  single  vesicle,  but  by  two, 
three,  or  more  punctures  close  set  together,  or  by  scar- 
ifications or  abrasions  over  some  extent  of  surface,  in 
a  manner  that  will  hereafter  be  described  (§  50,  c.  3), 
so  that  two,  three,  or  more  vesicles  are  developed  in 
close  proximity,  these  usually  coalesce,  and  a  vesicle 
results,  the  compound  character  of  which  is  very  ob- 
vious ;  or  there  may  be  a  crop  of  coalescent  vesicles, 
each  having  its  distinct  head  with  characteristic  depres- 
sion. These  compound  vesicles  and  crops  are  round, 
oval,  or  of  irregular  outline,  according  to  the  manner 
in  which  they  have  been  induced,  and  the  shape  of  the 
resulting  cicatrices  varies  accordingly. 

The  clear,  smooth,  supple,  delicate  skin  of  the  infant 
is  peculiarly  adapted  for  manifesting  in  perfection  the 
local  characters  of  the  vaccine  disease.  In  elder  chil- 
dren, and  much  more  in  adults,  though  the  phenomena 
of  primary  vaccination  are  essentially  the  same  as  in 
the  infant,  the  vesicle  is  often  wanting  in  that  plump- 
ness, sharp  definition  of  edge,  and  beautiful  luster, 
which  the  experienced  vaccinator  delights  to  see. 

35.  Constitutional  Symptoms;  Vaccine  Roseola, 
Vaccine  Lichen,  etc — In  some  instances  constitutional 
symptoms  are  noticed  before  the  formation  of  the  areola 
— never,  however,  amounting  to  more  than  a  little  fe- 
verishness  and  fretfulness,  most  observed  in  the  even- 
ing, and  remitting  in  the  morning,  about  the  sixth  or 
seventh  day;*  but  in  elder  children,  and  still  more  in 

*  From  notes  with  which  Mr.  Squire,  of  Orchard  Street, 
has  favored  me,  of  a  few  observations  made  by  him  on  the 


84  HANDBOOK  OF   VACCINATION. 

adults,  who  arc  the  subjects  of  primary  vaccination, 
these  early  symptoms  are  usually  more  marked.  The 
amount  of  the  constitutional  affection  which,  two  or 
three  days  later,  attends  the  development  of  the  areola 
(see  previous  section),  varies  in  different  subjects  with 
the  texture  and  vascularity  of  the  parts,  with  the  ex- 
tent of  local  inflammation,  and  with  the  temperament 
and  age  of  the  individual ;  infants  suffer  usually  less 
than  elder  children,  and  these  less  than  adults.  But, 
even  with  the  most  perfect  areola,  the  general  symp- 
toms are  often  very  trifling.  In  adolescents  and 
adults  the  course  of  primary  cow-pox  is  apt  to  be 
somewhat  more  retarded  than  in  infants,  the  areola  is 
frequently  much  more  diffuse,  and  there  is  much  oftener 
swelling  of  the  axillary  glands.  In  young  children  of 
full  habit,  especially  in  hot  weather,  about  the  ninth  or 
tenth  day,  when  the  areola  is  at  its  height,  an  eruption 
of  roseola  will  occasionally  take  place,  especially  on 
the  extremities ;  sometimes  the  eruption  takes  a  papu- 
lar form,  constituting  what  is  termed  vaccine  lichen  ; 
sometimes  it  is  vesicular.'  In  the  latter  case,  however, 
the  vesicles  have  no  resemblance  to  the  cow-pox  vesi- 
cles, but  are  more  like  those  of  chicken-pox ;  that  dis- 
ease, in  fact,  occurring  in  the  course  of  a  vaccination, 
might  easily,  without  due  care  and  inquiry,  be  mis- 
taken for  the  vesicular  eruption  which  occasionally 
attends  the  course  of  regular  vaccine.     But  the  occur- 


temperature,  as  indicated  by  the  thermometer,  of  children  at 
different  stages  of  vaccination,  it  appears  probable  that  a  rise 
will  generally  be  found  existing  by  the  sixth  day,  or  even  per- 
haps a  day  earlier.  Mr.  Squire  is,  I  believe,  continuing  these 
interesting  observations. 


COW-POX  IN  THE  HUMAN  SUBJECT.  85 

rence  of  any  of  these  forms  of  eruption  during  vaccin- 
ation is  the  exception  and  not  the  rule  :  when  they  do 
occur,  their  duration  is,  for  the  most  part,  very  transi- 
tory, usually  not  extending  beyond  a  week,  and  very 
seldom  indeed  lasting  beyond  the  falling  of  the  scab. 
Their  appearance  is  almost  limited  to  the*  period  of 
childhood:  they  are  very  rarely  seen  on  adolescents  or 
adults. 

36.  Abnormal  course. — But  vaccinia  in  the  human 
subject  does  not  invariably  follow  the  course  above 
described.  Its  progress  may  be  (a)  retarded,  (b)  ac- 
celerated, or  (c)  altogether  irregular  and  spurious. 

(a)  Retarded  Cow-pox. — The  most  simple  and  fre- 
quently seen  form  of  retardation  is  a  mere  delay  of  a 
day  or  two  in  the  course  of  the  vesicle ;  by  the  eighth 
day  this  has  not  more  size  and  development  than  or- 
dinarily it  has  on  the  sixth,  and  the  areola  does  not 
form  till  the  tenth  day,  or  even  later.  This  amount  of 
retardation  is  held  by  many  experienced  vaccinators  to 
be  more  frequently  met  with  in  cold  weather,  especially 
during  the  prevalence  of  a  dry  easterly  wind,  in  persons 
who  are  much  exposed  to  the  air.  Sometimes  a  longer 
delay  occurs ;  at  the  end  of  a  week  from  the  vaccination, 
when  the  child  is  brought  for  inspection,  there  is  so 
little  evidence  of  result,  that  it  is  a  question  whether  the 
vaccination  has  not  altogether  failed ;  some  fresh  lymph 
is  inserted  on  other  spots,  and  as  the  vesicles  of  the 
new  vaccination  rise,  those  of  the  first  vaccination  are 
seen  also  to  develop  themselves,  the  two  vaccinations 
running  their  course  at  the  same  time.  Bousquet  re- 
fers to  a  case  (not  in  his  own  practice)  in  which  this 
sort  of  revival  of  a  dormant  vaccination  was  said  to 
8* 


86  HANDBOOK  OF   VACCINATION. 

have  been  brought  about  at  the  end  of  three  weeks.* 
But  without  any  recourse  to  a  second  vaccination,  it 
will  sometimes  be  found  that  vesicles  will  rise  some 
days,  or  a  week,  or  more,  after  the  usual  period,  and 
when  success  had  ceased  to  be  looked  for.  A  tardy 
development  of  the  vesicle  occurs  much  more  frequently 
when  the  vaccination  has  been  done  with  dry  lymph 
than  when  it  has  been  performed  direct  from  the  arm. 
In  many  of  these  cases,  indeed,  the  vaccine  process  can 
scarcely  properly  be  said  to  have  been  retarded ;  the 
lymph,  no  doubt,  at  the  time  that  it  was  deposited  on 
the  cutis,  was  in  a  dry  or  undissolved  state,  and  it 
simply  waited  solution  to  be  taken  up  by  the  system. 
A  mere  retardation  of  cow-pox  in  a  healthy  individual 
does  not  in  the  least  impair  its  protective  value,  pro- 
vided only  the  phenomena  be  regular  in  their  char- 
acter. 

Effects  of  incubation  of  Measles,  Scarlatina,  etc.  on 
course  of  Cow-pox. — Certain  temporary  conditions  of 
the  system  may  operate  to  retard  cow-pox.  If  vac- 
cination has  been  successfully  performed  during  the  in- 
cubation of  measles,  but  the  vesicles  have  not  reached 
their  mature  or  areolar  stage  by  the  time  that  disease 
manifests  itself,  it  will  very  frequently,  if  not  usually, 
be  found  that  they  will  not  go  through  that  stage  until 
such  time  as  the  measles  have  subsided.  In  such 
cases  the  areola  may  not  be  formed  till  a  fortnight  or 
more  after  vaccination,  or  it  may  not  be  formed  at  all. 
The  same  has  been  observed  with  regard  to  scarlatina 
and  chicken-pox,  and  the  early  or  febrile  stage  of  hoop- 

*  Nouveau  Traite  de  la  Vaccine,  p.  17G. 


COW-POX  IN  THE  HUMAN  SUBJECT.  87 

ing-cough.*  Jenncr  gives  a  very  interesting  account 
of  two  sisters  in  whom  scarlatina  manifested  itself  on 
the  eighth  day  from  vaccination.  In  one,  the  vaccine 
vesicle  remained  at  its  maturity,  but  "  there  was  a 
total  suspension  of  areola  till  the  scarlatina  had  retired 
from  the  constitution ;"  as  soon  as  this  occurred,  the 
areola  advanced  in  the  usual  way.  In  the  sister,  the 
symptoms  indicative  of  scarlatina  came  on  severely  for 
about  twelve  hours;  then  a  rash  showed  itself  faintly 
upon  the  face  and  part  of  the  neck,  but  in  two  or  three 
hours  suddenly  disappeared,  and  the  patient  was  free 
from  every  complaint ;  it  was  then  observed  that  the 
vesicle  had  the  usual  areola,  and  this  continued  till  the 
fourth  day,  when  it  subsided,  and  scarlatina  again  ap- 
peared, and  went  through  its  course  with  the  common 
symptoms,  f  It  is  not  always,  however,  that  scarla- 
tina, or  measles,  or  chicken-pox  acts  thus  on  the  course 
of  cow-pox,  or  cow-pox  on  them ;  vaccination  has  been 
repeatedly  seen  running  its  course  along  with  them  and 
uninfluenced  by  them.  J  The  course  of  cow-pox  when 
accompanied  by  any  of  the  specific  febrile  eruptive  dis- 
eases should  be  watched  most  carefully  throughout, 

*  See  interesting  cases  in  point  by  Aikin,  London  Med. 
Gazette,  vol.  xiii.  p.  752,  seq.;  also  Addington's  eleventh  and 
twelfth  cases,  as  cited  by  Ring,  Treatise  on  Cow-pox,  p.  524. 

f  A  continuation  of  Facts  and  Observations,  etc. 

X  Jenner  (Further  Observations,  etc.,  p.  137)  gives  a  case  of 
this  kind.  Various  instances  will  be  found  recorded  in  Ring 
(op.  eit.).  He  also  relates  several  cases  of  small-pox  and  measles, 
running  their  course  together,  uninfluenced  the  one  by  the 
other;  and  one  case  in  which  small-pox,  measles,  and  hooping- 
cough  coexisted.  (See,  particularly  on  this  subject,  Marson's 
Paper  on  the  Coexistence  of  the  Eruptive  Fevers,  Med.-Chir. 
Trans.,  vol.  xxx.) 


88  HANDBOOK  OF   VACCINATION. 

and  no  warrant  of  protection  against  small-pox  given 
unless  a  regular  areola  has  been  developed. 

Effects  of  incubation  of  Small-pox. — When  vaccina- 
tion has  been  performed  on  any  one  who  is  incubating 
small-pox,  if  the  incubation  of  that  disease  be  so  far 
advanced  that  the  small-pox  manifests  itself  within  two 
or  three  days  of  the  vaccination,  no  vaccine  vesicles 
will  rise,  but  small-pox  only  will  be  developed.*  But 
if  the  incubation  has  been  less  advanced,  and  the  cow- 
pox  has  taken  local  effect  before  the  small-pox  symp- 
toms s,et  in,  the  further  progress  of  the  vaccination 
may,  or  may  not,  be  retarded.  Very  frequently  the 
two  diseases  will  be  seen  going  on  together,  so  distinct, 
the  one  from  the  other,  that  lymph  from  the  cow-pox 
vesicles  will  certainly  produce  cow-pox  and  cow-pox 
only,  and  lymph  from  the  small-pox  vesicles  will  pro- 
duce small-pox  and  small-pox  only.f  If,  however,  the 
cow-pox  vesicles  had  not  reached  the  stage  -of  areola 
before  the  small-pox  set  in,  no  influence  will  be  pro- 
duced on  the  course  of  the  small-pox ;  if,  on  the  other 
hand,  the  areola  be  fully  formed  round  the  cow-pox 
vesicles  before  the  small-pox  symptoms  appear,  the 
vaccination  will,  according  to  its  date,  either  arrest 
the  small-pox  at  its  premonitory  stage,  or  alter  and 

*  Under  these  circumstances  variolous  vesicles  will  often  be 
met  with  on  the  vaccinated  spots.  (See  cases  in  point,  King's 
Treatise,  etc.,  pp.  483  and  525.  Also  "Willan  oil  Vaccine  In- 
oculation, p.  8,  note.) 

f  So  distinct  are  they,  that  the  variolous  pustule  may  be 
developed  within  the  margin  of  the  vaccine  vesicle,  and  matter 
taken  from  it  produce  small-pox,  while  fluid  taken  from  the 
opposite  edge  of  the  vesicle  communicates  cow-pox.  (See 
Willan  on  Vaccine  Inoculation,  p.  6,  note.) 


COW-POX  IN  THE  HUMAN  SUBJECT.  89 

modify  the  course  of  the  eruption.  This  is  a  distinc- 
tion of  great  practical  importance,  to  which  I  shall 
further  advert  hereafter  (§  50,  a).  In  consequence  of 
the  frequent  delay  of  parents  to  have  their  children 
vaccinated  until  epidemics  of  small-pox  break  out,  it 
is  no  uncommon  thing  to  see  variola  and  vaccinia  con- 
current. 

(b)  Accelerated  Cow-pox. — A  hastened  course  of 
the  cow-pox  vesicle  is  to  be  regarded  with  much  more 
suspicion,  in  reference  to  its  effect  on  the  protection  of 
the  individual,  than  a  retarded  course,  for  spurious 
vaccination  is  generally  accelerated.  There  may  be, 
however,  simple  acceleration — a  course  some  twelve  or 
twenty -four  hours  in  advance  of  the  usual  course ;  the 
vesicle  on  the  eighth  day  being  in  the  state  in  which  it 
is  usually  seen  on  the  ninth,  the  areola  nevertheless 
being  regular,  and  the  crust  being  subsequently  duly 
formed.  In  such  cases  the  protective  value  of  the  vac- 
cination is  not  impaired. 

(c)  Spurious  Cow-pox. — "Vaccination  sometimes 
runs  an  entirely  irregular  course.  The  varieties  of 
irregularity  are  considerable.  In  the  form  most  fre- 
quently seen,  the  course  resembles  very  closely  that  of 
a  revaccination  (§  4?)  :  the  vesicle  begins  with  itching 

/  and  irritation ;  it  is  acuminated  or  conoidal,  instead  of 
being  flat  and  with  central  depression,  and  it  contains 
straw-colored  or  opaque  fluid,  instead  of  clear  lymph ; 
it  has  an  early  and  irregular  areola,  which  is  at  its 
height  by  the  fifth  or  sixth  day,  and  when  seen  on 
the  day  week  is  far  on  the  decline;  there  is  then  a 
small  scab  on  the  surface  which  usually  drops  off  by 
the  tenth  day.  The  local  effect  in  some  cases  is 
much  less  than  this,  and  on  the  day  week  there  is  no- 


90  HANDBOOK  OF   VACCINATION. 

thing  to  be  seen  but  a  very  thin  scab  or  scale  just 
about  to  detach  itself,  and  which  at  the  lightest  touch 
falls  off.  In  other  cases,  the  vesicles,  when  seen  on 
the  eighth  day,  are  found  to  have  burst,  and  present  an 
irregular  pustuloid  or  scabby  appearance,  or  are  so 
many  open  sores.  It  would  be  difficult,  and  is  quite 
unnecessary,  to  give  a  minute  verbal  description  of 
each  form  of  irregularity  that  may  be  observed ;  the 
real  important  practical  point  being,  that  a  vaccination 
presenting  any  deviation  from  the  perfect  character  of 
the  vesicle,  and  the  regular  development  of  the  areola, 
is  not  to  be  relied  on  as  protective  against  small-pox. 

Causes  of  Spurious  Cow-pox. — A  spurious  and  ir- 
regular course  of  the  vaccine  vesicle  is  sometimes  seen 
to  occur  where  no  cause  can  be  assigned  for  it,  as  in  a 
child  apparently  perfectly  healthy,  and  when  the  vac- 
cination has  been  done  by  a  careful  and  experienced 
hand,  with  lymph  which  in  other  children  has  produced 
only  its  normal  effects.  Occasionally  the  best  vaccin- 
ator may  find  that  on  a  particular  day  some  of  his  cases, 
done  probably  from  different  sources,  present  more  or 
less  of  deviation  from  the  normal  results — whence  it 
has  been  assumed,  for  want  of  other  explanation,  that 
there  may  be  an  occult  and  indefinable  influence  of 
season  or  weather.  But  these  are  the  exceptions — the 
rare  exceptions  ;  and  far,  far  more  commonly,  spurious 
vaccination  may  be  traced  directly  to  one  of  two  causes 
— either  to  the  use  of  lymph  which  was  not  well  chosen 
by  the  vaccinator  or  which  has  been  spoilt  in  the  stor- 
age or  keeping,  or  to  something  amiss  in  the  state  of 
the  child  vaccinated.  The  former  of  these  causes  is 
illustrated  by  the  occurrence  of  various  forms  of  ir- 
regularity in  several  children,  vaccinated  all  from  one 


COW-POX  IN  THE  HUMAN  SUBJECT.  91 

and  the  same  source ;  the  latter  in  children  vaccinated 
from  unexceptionable  sources,  but  in  whom  the  pres- 
ence, at  the  time  of  vaccination,  of  one  or  other  of  those 
affections  which,  like  herpes,  intertrigo,  etc.,  frequently 
interfere  materially  with  the  regular  progress  of  the 
vaccine  vesicle,  had  been  overlooked  or  disregarded.* 

*  My  experience  supplies  me  with  numerous  instances  of 
cither  kind.  Some  two  or  three  years  ago  I  saw  nine  chil- 
dren who  had  been  vaccinated  the  day-week  previous,  in  each 
of  whom  the  vaccination  was  running  an  irregular  course.  I 
found  on  inquiry  that  they  had  all  been  done  from  one  source, 
and  that  a  source  which,  from  the  description  given  of  it, 
ought  not  to  have  been  employed — a  case  in  which  the  lymph 
was  thin  and  serous,  running  down  the  arm  in  profusion  when 
the  vesicles  were  opened.  On  a  subsequent  occasion  I  saw,  in 
a  large  town  in  the  south  of  England,  spurious  results  in  every 
one  of  several  children  vaccinated  the  day-week  previous,  it 
was  believed  all  from  one  child ;  and  one  of  these  irregular 
cases  was  being  used  for  the  vaccination  (?)  of  some  more  chil- 
dren. The  other  kind  of  error  is  of  more  frequent  occurrence  ; 
and  seldom  many  weeks  pass  but  that  I  see  some  irregular 
case  or  another,  and  am  able,  by  looking  behind  the  ears  of 
the  child,  or  in  the  folds  of  its  neck,  etc.,  to  point  out  to  the 
vaccinator  the  cause  of  the  irregularity.  "  If  we  see  the  vac- 
cine pustule,"  says  Jenner,  "straying  a  few  days  after  the 
insertion  of  the  vaccine  fluid,  we  must  not  be  content  with  a 
superficial  examination  of  the  skin  of  our  patient,  but  we  shall 
find  it  necessary  to  make  a  more  minute  inquiry.  For  after 
a  general  examination  without  detecting  conspicuous  herpetic 
blotches,  we  shall  find  perhaps  that  the  child  has  an  herpetic 
eyelid,  a  speck  behind  the  ears,  or  an  excoriation  in  other 
parts  oozes  out  this  fluid,  which  produces  impediment.  I  find 
that  in  many  instances  an  abraded  cuticle,  not  larger  than  the 
surface  of  a  split  pea,  is  as  capable  as  a  blotch  of  fifty  times 
the  extent,  of  producing  this  effect."  (Letter  to  Dr.  Labatt, 
Jan.  H,  1821,  in  Dub.  Quar.  Journal  of  Med.  Sci.,  vol.  xxvii. 
p.  471.) 


92  HANDBOOK  OF   VACCINATION. 

The  best  proof  how  much  irregular  and  abnormal  re- 
sults of  vaccination  are  dependent  on  the  want  of  care 
and  skill  of  vaccinators,  is  the  frequency  with  which 
they  are  seen  in  the  hands  of  some  vaccinators,  and 
their  great  comparative  rarity  in  the  hands  of  others. 

37.  Effects  of  Mechanical  Interference. — Mechani- 
cal irritation  of  the  vesicles  of  cow-pox,  friction  of  the 
clothes,  scratching  with  the  nails,  etc.,  may  cause  the 
vesicles  to  be  prematurely  ruptured,  and  may  otherwise 
materially  affect  the  course  of  the  disease;  they  should 
always  therefore  carefully  be  guarded  against.  These 
occurrences  are  more  frequently  met  with  in  children 
who  are  past  babyhood  when  they  are  vaccinated,  than 
in  young  infants.  But  it  is  not  at  all  an  un frequent 
thing  to  find  a  spoilt  and  broken  appearance  of  the  ves- 
icles on  the  eighth  day  ascribed  to  rubbing,  when  in 
fact  it  is  really  a  form  of  spurious  vaccination  resulting 
from  one  or  other  of  the  causes  stated  in  the  preceding 
paragraph.* 

*  It  is  an  interesting  subject  of  inquiry  how  far  a  vaccina- 
tion, the  vesicles  of  which  have  been  early  broken,  or  are  other- 
wise spoilt  or  spurious,  affects,  or  may  affect,  the  constitution 
as  regards  its  liability  to  small-pox.  In  some  cases  of  this 
kind,  vaccination  duly  performed  soon  afterward  goes  through 
its  regular  course  as  if  nothing  had  been  done  before  ;  and  in 
such  cases  we  can  have  no  doubt  that  the  effect  of  the  first 
vaccination  had  been  nil.  But  oftentimes,  after  spurious  re- 
sults, a  repetition  of  the  vaccination  will  only  produce  an  ir- 
regular and  incomplete  effect.  Yet  we  have  abundant  evidence 
that  persons  whose  vaccination  has  been  disturbed  or  imper- 
fect are  liable,  if  they  do  not  take  care  to  get  revaccinated, 
to  contract  small-pox  and  to  have  it  badly.  Ceely  mentions 
having  met  at  different  times  with  several  cases  in  which  vac- 
cination took  imperfectly,  and  in  which  subsequent  vaccina- 


COW-POX  IN  THE  HUMAN  SUBJECT.  93 

38.  Degeneration  of  the  Vaccine  Vesicle  ;  Erysipe- 
las, etc. — In  a  small  proportion  of  cases  vaccination, 
especially  if  it  has  taken  effect  in  a  hastened  or  spurious 
form,  will  in  its  course  manifest  inflammatory  symp- 
toms of  considerable  activity,  and  very  sore  arms  will 
result;  the  vesicle  degenerating  into  a  purulent  ulcer, 
or  sometimes  into  a  sloughing  sore,  leaving  a  cicatrix 
which  has  none  of  the  characteristic  pittings,  but  is 
simply  a  puckering,  or  a  flat,  smooth,  shining  scar.  In 
a  still  smaller  proportion  of  cases  true  erysipelas  may 
occur.  These  events,  it  need  scarcely  be  said,  deprive 
the  cow-pox  of  its  specific  protective  power.  Small- 
pox, and  of  a  very  severe  kind,  is  frequently  met  with 
in  persons  having  the  sort  of  cicatrix  just  described. 
Lymph  taken  from  revaccination  cases,  or  from  spu- 
rious primary  cases,  or  the  lymph  of  normal  primary 
cases,  if  taken  at  too  late  a  period  of  the  vesicle,  or  if 
kept  so  as  to  have  become  partially  decomposed,  may 
give  rise  to  these  consequences ;  but  at  other  times 
they  are  met  with  where  no  possible  fault  can  be  found 
with  the  lymph,  other  children  vaccinated  with  the 
same  lymph  going  through  their  vaccination  in  a  per- 
fectly normal  way.  The  cause  must  then  be  looked 
for  either  in  the  constitution  and  habit  of  body  of  the 
child  vaccinated,  or  (so  far  as  erysipelas  is  concerned) 

tion  three  or  four  months  after  took  (not  perfectly,  hut)  less 
imperfectly.  But  one  of  these  cases  failing  to  appear,  for  re- 
vaccination,  as  desired,  sustained  ahout  ten  years  afterward  a 
severe  attack  of  small-pox.  (See  an  interesting  note  at  p.  411 
of  his  Memoir,  op.  cit.)  Practically,  revaccination  should 
always  be  carefully  performed,  whenever  there  has  been  any 
irregularity,  whether  from  mechanical  disturbance  or  other- 
wise, in  the  character  of  the  tirst  vaccination. 

9 


94  HANDBOOK  OF   VACCINATION 

in  the  "  constitution  of  the  air,"  to  use  Sydenham's 
convenient  form  of  expression.  Accordingly,  cases  of 
erysipelas  following  vaccination,  when  they  do  occur, 
are  not  unfrequently  met  with  two  or  three  together  in 
one  locality,  and  at  times  when  erysipelas  is  noticed 
as  attending  wounds  from  other  surgical  operations. 

39.  Effects  of  Climate  on  the  course  of  Vaccination. 
— In  climates  like  our  own,  or  in  colder  countries,  the 
utmost  effect  of  season,  of  hotter  or  of  colder  weather, 
is  but  to  accelerate  or  to  retard  (and  that  only  excep- 
tionally, and  seldom  beyond  a  few  hours)  the  course  of 
vaccination  ;  but  the  heat  and  moisture  which  at  cer- 
tain seasons  of  the  year  prevail  within  the  tropics,  and 
in  places  with  tropical  climates,  interfere  considerably, 
according  to  the  best  authorities,  with  the  regular  pro- 
gress of  the  vaccine  disease.  In  the  northwest  pro- 
vinces of  India,  and  to  a  less  degree  in  Bengal,  it  has 
been  observed  that,  after  the  hot  season  has  set  in, 
vaccination  is  less  successful ;  that  in  Calcutta,  for  in- 
stance, it  is  only  among  the  European  and  better-off 
classes,  who  can  afford  to  look  after  their  children,  and 
protect  them  properly  from  the  heat,  that  vaccination 
can  at  this  season  be  prudently  performed.*  But  the 
rainy  season  is  even  more  inimical  to  successful  vac- 
cination in  Bengal.  At  that  period  of  the  year,  "in 
some,  if  not  all,  the  districts  of  Lower  Bengal,  the  sim- 
ple puncture  for  the  insertion  of  vaccine  virus  fre- 
quently produces  violent  inflammation,  which  either 
degenerates  into  foul  sloughing  sores,  or  the  same  de- 
generation succeeds  to  the  maturation  of  the  vesicle. 

*  See  Keport  of  the  Small-pox  Commissioners  appointed  by 
the  (Indian)  Government  in  1850,  pp.  50,  51. 


COW-POX  IN  THE  HUMAN  SUBJECT.  % 

In  both  cases  vaccination  must  necessarily  be  suspended 
for  a  time."*  The  Bengal  Sanitary  Commissioners 
have  recently  also  stated  that  the  cool  season  of  the 
year  is  that  in  which  alone  vaccination  can  usually  be 
practiced  with  success  in  the  plains  of  India,  though 
in  the  more  temperate  climate  of  the  hills  it  can  be 
carried  on  almost  throughout  the  year.f  In  most 
parts  of  the  Bombay  Presidency,  and  in  Sind,  as  would 
appear  from  the  annual  official  reports,  vaccination  is 
carried  out  at  all  seasons  of  the  year.  None,  or  scarcely 
any,  of  the  surgeons  officially  employed  in  the  perform- 
ance and  direction  of  vaccination  in  that  Presidency, 
find  it  necessary  to  omit  vaccinating  on  account  either 
of  the  hot  or  the  rainy  season.  But  some  of  them 
state  that  at  these  periods  of  the  year  difficulty  is  ex- 
perienced in  keeping  lymph,  so  that  they  are  obliged 
to  be  then  especially  careful  to  maintain  a  series  of 
cases  from  arm  to  arm ;  and  some  also  note  that  the 
operations  are  attended  with  a  minor  degree  of  success, 
and  with  occasional  deterioration  of  the  vaccine  vesicle.  J 
It  would  appear,  on  the  whole,  that  in  the  cooler  parts 
of  India  vaccination  may  be  performed  at  any  period 
of  the  year,  but  that  in  the  hotter  parts  the  best  months 
for  vaccinating  are  from  October  till  March.  The  ex- 
perience of  Dr.  John  Davy,  in  Ceylon  and  in  the  West 
Indies,  induced  him  to  consider  the  cool  season,  the 
winter  months,  as  the  best  for  vaccinating  within  the 
tropics. 

*  See  Report  of  the  Small-pox  Commissioners  appointed  by 
the  (Indian)  Government  in  1850,  p.  51. 

-}•  First  Annual  Report,  p.  60. 

\  Reports  (presented  annually)  on  Vaccination,  throughout 
the  Bombay  Presidency  and  Sind. 


96  HANDBOOK  OF  VACCINATION. 

40.  Supernumerary  Vesicles. — A  very  interesting, 
but  quite  exceptional,  phenomenon  in  the  course  of  vac- 
cination is  the  development  of  vaccine  vesicles  on  parts 
of  the  body  where  no  vaccine  lymph  had  been  inserted ; 
these  are  termed  "  supernumerary  vesicles."  They  are 
sometimes  only  two  or  three  in  number,  at  other  times 
eight,  ten,  twenty,  or  more,  in  various  situations  over 
the  body  and  limbs.  Accidental  supernumerary  vesi- 
cles— the  result  of  a  chance  puncture  with  a  lancet 
charged  with  vaccine  lymph,  or  of  an  accidental  appli- 
cation of  lymph  to  an  abraded  surface — are  by  no 
means  rare ;  but  the  phenomenon  to  which  I  refer  is 
the  development  of  vesicles  where,  it  is  believed,  none 
of  these  accidental  occurrences  can  have  taken  place — 
vesicles  which  are  really  eruptive,  and  which  neverthe- 
less, as  proved  by  the  effect  of  vaccinating  from  them, 
are  of  genuine  vaccine  character.  The  cares  on  record 
seem  to  establish  that  real  eruptive  supernumerary 
vesicles  mmj  occur  in  the  course  of  an  ordinary  vaccin- 
ation ;  but  so  rare  at  all  events  is  their  occurrence, 
that  Bousquet,  in  his  long  career,  has  only  seen  two  or 
three  instances  of  them  (which,  he  says,  at  the  time 
satisfied  his  mind,  but  concerning  which  on  subsequent 
reflection  he  has  been  led  to  entertain  doubts) ;  and 
Marson's  vast  experience,  which  amounts  to  about 
60,000  vaccinations,  does  not,  he  informs  me,  enable 
him  to  say  more  than  that  he  has  seen  cases  of  addi- 
tional vesicles  which  he  thinks  were  eruptive.*     In  all 

*  Like  many  practitioners,  I  have  seen  cases  of  supernume- 
rary vesicles,  but  never  of  any  which  I  could  regard  as  erup- 
tive. M.  de  Paul  stated,  in  a  discussion  at  the  Acad.  Imp.  de 
Med.,  that  he  had  seen  five  cases  of  eruptive  vesicles,  but  gave 
no  particulars  of  them.  (Bull,  de  l'Acad.,  tome  xxix.  p.  203.) 


COW-POX  IN  THE  HUMAN  SUBJECT.  97 

cases  of  "supernumerary  vesicles,"  we  are  not  justi- 
fied in  regarding  these  as  an  eruption  of  vaccine  until 
we  have  satisfied  ourselves,  first,  that  the  vesicles  are 
of  real  vaccine  character,  and  not  an  ordinary  vesicular 
eruption  attendant  on  cow-pox — this  may  be  inferred 
from  their  appearance,  but  proved  by  inoculating  the 
fluid  from  them ;  secondly,  that  the  vesicles,  if  genuine, 
are  not  after  all  accidental,  the  result  of  an  uninten- 
tional inoculation  of  lymph  by  the  vaccinator,  by  the 
child,  or  by  its  nurse — for,  as  Ceely  justly  remarks, 
"  It  is  rare,  indeed,  for  them  to  be  found  on  spots  to 
which  lymph  might  not  have  been  directly  applied," 
and  if  the  lymph  be  good  and  active,  it  is  not  indispens- 
able that  the  skin  should  have  been  visibly  abraded  ;* 

In  the  Annual  Keports  of  the  vaccinations  in  France  for 
twenty-four  years  (1841-64)  I  find  but  eight  cases  of  super- 
numerary vesicles  reported  by  the  different  vaccinators,  and 
in  four  of  these  the  accounts  render  it  probable  that  the  super- 
numerary vesicles  were  accidental.  Three  of  the  remaining 
four  cases  stand  entirely  on  the  accuracy  and  habits  of  obser- 
vation of  the  individual  reporters,  and  it  can  scarcely  be  said 
of  all  of  them  that  the  accounts  are  quite  conclusive.  But  in 
one  case  (in  1841)  the  whole  circumstances,  the  existence  of 
the  supernumerary  vesicles  and  the  results  of  the  vaccinations 
performed  from  them,  were  watched  by  members  of  the  Vac- 
cine Commission  of  the  Academic 

*  "  Use  active  liquid  lymph  in  great  abundance  to  every 
puncture,  made  so  as  to  draw  blood  rather  freely;  wipe  the 
lancet  over  the  puncture,  leaving  it  covered  all  around  with 
lymph  ;  take  care,  by  attention  to  position,  etc.,  that  the  blood 
shall  dry  over  and  around  the  wound,  and  thus  cover  the 
_lymph.  It  will  often  happen,  in  young  and  favorable  skins, 
that  one  or  two  supernumerary  vesicles  will  appear  at  a  greater 
or  less  distance  from  the  punctures,  which,  in  time,  nearly  or 
completely  coalesce.     Sometimes  they  will  appear  even  two  or 

9* 


98  HANDBOOK  OF   VACCINATION. 

and,  thirdly  (and  this  applies  particularly  to  those  cases 
in  which  the  supernumerary  vesicles  are  many  in  num- 
ber, and  have  somewhat  of  the  character  of  a  general 
eruption),  that  we  have  not  mistaken  for  vaccine  vesi- 
cles an  eruption  of  modified  variola  accompanying 
vaccinia,  such  as  happens  in  a  person  vaccinated  during 
the  incubation  of  small-pox — the  variolous  eruption 
under  such  circumstances  being  often  very  sparse,  and 
the  vaccine  vesicles  and  small-pox  vesicles  more  or  less 
resembling  one  another.  Each  of  these  kinds  of  mis- 
take has  been  made,  and  the  second  kind,  viz.,  that  of 
mistaking  accidental  for  eruptive,  supernumerary  vesi- 
cles, very  often  made. 

41.  Reinsertion  of  Vaccine  Lymph  within  five  days 
of  a  successful  Insertion;  Bryce's  Test. — If,  at  any 
period  not  later  than  the  fifth  day  from  the  successful 
insertion  of  vaccine  lymph  into  the  arm  of  a  child,  a 
fresh  insertion  of  lymph  be  made,  this  second  vaccina- 
tion will  take  effect  as  certainly  as  if  no  previous  vac- 
cination had  been  done ;  but  the  vesicles  arising,  while 
corresponding  in  size  to  the  date  of  their  origin,  will 
overtake  in  their  course  the  vesicles  first  made,  will  ar- 
rive at  maturity  and  will  fade  at  the  same  time  with 
them.     Thus,  if  a  child  be  vaccinated  with  effect  on  a 

three  inches  distant  from  the  puncture,  when  the  blood,  mixed 
with  lymph,  has  trickled  down  and  dried  there."  (Ceely,  in 
Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  326,  note.) 
In  one  case  a  vesicle,  produced  in  this  way  at  a  distance  of 
four  inches  from  the  inoculated  vesicles,  attained  on  the  twelfth 
day  the  size  of  a  small  horse-bean,  and  having  no  firm,  con- 
nection with  the  skin  at  its  center,  like  the  casual  vesicle  on 
the  cow,  it  acuminated  on  the  eleventh  day,  as  perfectly  as  on 
that  animal.     (Ibid.,  p.  400,  note.) 


COW-POX  IN  THE  nUMAN  SUBJECT.  99 

certain  day,  and  some  good  active  vaccine  lymph  be 
inserted,  say  on  the  fourth  or  fifth  day  afterward,  the 
vesicles  of  this  second  insertion  will  by  the  tenth  day 
of  the  original  vaccination  not  usually  be  larger  than 
ordinary  vesicles  of  the  sixth  or  fifth  day,  but  they  will 
have  an  areola  as  advanced  as  the  areola  round  the  ves- 
icles of  the  first  insertion,  and  the  incrustation  and  fur- 
ther progress  of  the  two  inoculations  will  go  on  simul- 
taneously. Had  the  second  insertion  been  made  a  day 
or  two  earlier,  as  by  the  second  or  third  day  of  the 
vaccination,  the  vesicles  developed  by  it  would  have 
got  larger  by  the  time  the  first  insertion  was  at  its 
maturity  than  in  the  case  just  cited ;  but,  just  as  in  it, 
whatever  was  the  day  of  maturity  of  the  first  inser- 
tion would  be  the  day  of  maturity  of  the  second. 
That  this  result,  however,  may  follow  a  second  inser- 
tion of  lymph,  such  insertion  must  be  always  made 
within  five  days,  i.e.  within  five  times  twenty-four 
hours,  from  the  primary  insertion.  If  it  be  delayed 
beyond  this,  it  will  fail ;  there  will  either  be  no  result 
or  a  mere  hard  papule.  No  doubt  there  are  apparent 
exceptions  to  this  rule,  and  cases  are  now  and  then 
met  with  where  lymph  takes  effect  though  not  inserted 
until  the  sixth  or  seventh  day  of  a  vaccination ;  but 
these,  it  will  be  found,  are  not  real  exceptions,  they 
are  simply  cases  in  which  the  course  of  the  vaccina- 
tion has  been  retarded,  the  areola,  instead  of  appear- 
ing on  the  eighth  day  of  the  first  insertion,  not  coming 
on  till  the  ninth  or  tenth. 

Its  history. — The  very  first  account,  indeed,  we  have 
of  any  experimental  reinsertion  of  lymph  during  the 
early  stages  of  a  vaccination,  was  in  a  retarded  case 
It  was  in  a  vaccination  performed  in  1T99,  by  .Tenner's 


100  HANDBOOK  OF   VACCINATION. 

friend  and  correspondent,  Henry  Hicks.  In  two  cases 
of  vaccination  in  which  the  arms  on  the  sixth  day  ap- 
peared to  be  not  much  more  forward  than  they  gener- 
ally are  on  the  third  or  fourth,  and  the  appearances 
were  somewhat  irregular,  he  two  days  afterward  in- 
serted some  fresh  lymph.  "The  second  inoculation 
seemed  to  make  immense  strides  to  overtake  the  first, 
and,  what  is  wonderful,  the  first  pustules  began  to 
change  their  character  and  to  put  on  the  true  vaccine 
character."*  Jenner  afterward  (in  1801)  made  an  ex- 
perimental inoculation  of  this  kind  on  a  child  with 
lymph  taken  from  the  vesicle  which  was  developing 
itself  on  the  child's  own  arm.f  But  it  was  Mr.  Bryce, 
of  Edinburgh — one  of  the  early  and  one  of  the  best 
writers  on  vaccination! — who  first  instituted  any  num- 
ber of  these  experiments,  or  who  suggested  any  prac- 
tical application  of  the  discovery.  Starting  with  the 
belief  that  there  might  be  a.  perfect  local  development 
of  the  phenomena  of  vaccination  without  such  affection 
of  the  system  as  would  impart  security  against  small- 
pox, he  thought  that,  by  inserting  lymph  always  on 
the  fourth  or  fifth  day  of  a  vaccination,  the  existence 
or  absence  of  this  constitutional  affection  might  effect- 
ually be  tested.  He  argued  that  unless  the  system 
were  preoccupied  by  the  vaccine  influence,  any  inocu- 
lation of  vaccine  lymph  would  of  course  produce  effects 
which  would  go  through  the  ordinary  periods  of 
action,  and  that  an  acceleration  or  cutting  short  of 
these  periods  was  to  be  taken  as  evidence  of  the  con- 

*  Baron's  Life  of  Jenner,  vol.  i.  p.  331. 
f  Ibid.,  vol.  i.  p.  450. 

\  Practical  Observations  on  the  Inoculation  of  Cow-pox, 
Edinb:  1802;  and  2d  edition,  1809. 


COW-FOX  IN  THE  HUMAN  SUBJECT.        101 

stitutional  affection  of  the  vaccine.  Hence  the  practice 
has  become  generally  known  as  "Bryce's  test."  He 
recommended  that  it  should  be  systematically  em- 
ployed. The  reasoning  is  ingenious,  and  the  phenom- 
ena are  interesting,  but  the  necessity  of  the  practice 
has  never  been  generally  admitted,  and  the  practice  it- 
self is  now  wholly  disused.  Jenner  recommended  it 
to  the  uninitiated,  but,  as  he  justly  observed,  the 
course  of  the  vaccination  will  be  sufficient  to  enable 
the  experienced  to  determine. 

Its  analogy  with  some  of  the  phenomena  of  natural 
Cow-pox. — The  analogy  presented  by  the  phenomena 
resulting  from  Bryce's  test,  to  some  of  the  appear- 
ances met  with  in  the  course  of  natural  cow-pox  in  the 
cow,  in  which  vesicles  are  seen  at  the  same  time  in 
various  stages  of  progress,  but  all  terminating  together 
(§  5),  can  scarcely  have  escaped  the  reader's  notice. 
Various  apparent  anomalies  in  the  course  of  the  disease 
in  the  cow  become  thus  readily  explicable.  "  No  sooner 
is  lymph  produced  in  the  cow,"  says  Ceely,  "  than  by 
pressure  in  the  recumbent  posture,  self-vaccination  may 
occur  ;  but  a  more  frequent  and  more  efficient  cause  are 
the  reiterated  manipulations  of  the  milkers.  These 
men,  night  and  morning,  in  the  performance  of  another 
task,  unconsciously  but  most  effectually  perform  on  an 
extensive  scale  a  very  important  process — a  series  of 
revaccinations  both  from  the  infecting  and  infected 
animals."* 

42.  Vaccination  with  Primary  Cow -Lymph. — 
When,  instead  of  vaccination  being  performed,  as  it 
usually  is,  with  lymph  that  has  been  long  humanized, 

*  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  p.  325. 


102  HANDBOOK  OF   VACCINATION. 

some  lymph  is  employed  which  is  derived  directly  or 
very  recently,  say  within  three  or  four  removes,  from 
the  natural  or  casual  disease  in  the  cow,  there  is  often 
considerable  difficulty  in  getting  it  to  take  effect. 
While  lymph  transferred  from  one  human  being  to 
another  will,  if  used  under  proper  conditions,  infect 
with  almost  unerring  certainty,  cow-lymph  will  fail  to 
infect  in  a  great  number  of  instances.  Ceely  found  that 
more  than  half  his  attempts  to  vaccinate  with  primary 
cow-lymph,  taken  from  vesicles  at  a  proper  stage  and 
possessing  all  the  characteristics  of  perfection,  resulted 
in  entire  failure,  the  same  individuals  being  success- 
fully vaccinated  immediately  afterward  with  the  cur- 
rent humanized  vaccine  lymph.  Of  the  cases  in  which 
the  cow-lymph  did  not  fail,  it  produced,  in  some,  only 
spurious  results;  in  others,  a  still  smaller  number,  it 
succeeded  perfectly;  but,  in  nearly  all  the  successful 
cases,  the  number  of  vesicles  seldom  equaled  one-half 
of  the  number  of  punctures.  Similar  phenomena  of 
entire  failure,  imperfect  vaccination,  or  complete  vac- 
cination, with  all  attendant  circumstances,  resulted  from 
the  use  of  lymph  from  perfect  casual  vesicles  on  the 
hands  of  milkers  ;  and  the  same  was  the  case  with  the 
early  removes  of  primary  cow-lymph  until  it  became 
humanized. 

Local  phenomena  and  general  symptoms. — In  all 
cases,  whether  successful  or  not,  the  insertion  of  pri- 
mary cow-lymph  induces  a  remarkable  and  unusual 
redness  at  the  point  of  puncture,  a  vivid  blush,  which 
gradually  declines  on  the  third  or  fourth  day,  and  when 
the  vaccination  fails  soon  entirely  disappears,  but  when 
it  is  successful  becomes  more  and  more  concentrated, 
and  at  length  blends  with  the  red  elevation  of  the  vac- 


COW-POX  IN  THE  nUMAN  SUBJECT.        103 

cine  pimple.  But  between  the  decline  of  the  blush  and 
the  commencement  of  papulation  there  is  often  an  in- 
terval, and  papulation  is  sometimes  postponed  till  the 
sixth,  seventh,  eighth,  or  even  tenth  day,  giving  rise  to 
corresponding  irregularity  in  the  period  of  full  develop- 
ment of  the  vesicle,  so  that  the  areola  is  frequently  not 
complete  till  from  the  eleventh  to  the  fourteenth,  or 
even  the  sixteenth  day.  At  this  period,  especially  in 
children,  small  supernumerary  vesicles  in  miniature 
often  appear  within  its  limits ;  sometimes  they  are  seen 
also  on  the  shoulder,  still  more  rarely  on  the  face  and 
body.  The  papular  and  vesicular  eruptions  which 
occasionally  attend  ordinary  vaccination  at  this  stage 
of  its  course  (§  35)  are  more  frequently  seen  when 
primary  cow-lymph  is  used.*  The  areola,  when  at  its 
height,  is  more  indurated  than  is  observed  in  vaccina- 
tion with  ordinary  humanized  lymph,  and  its  color  de- 
clines and  revives,  continuing  to  exhibit  a  brick-red  or 
purplish  hue  while  the  hardness  remains.  The  vesicles 
themselves  in  most  instances  are  not  more  developed 

*  Steinbrenner  noticed  the  more  frequent  occurrence  of  the 
papulo-vesicular  eruptions  attendant  on  vaccinia,  when  this 
has  been  produced  by  primary  cow-lymph  and  its  early  re- 
moves, than  when  old  lymph  is  used.  In  seven  out  of  twenty 
children  vaccinated  with  lymph  at  the  first,  third,  or  twelfth 
removes  from  the  cow,  there  was  a  secondary  papulo-vesicular 
eruption  from  the  twelfth  to  the  sixteenth  day  ;  but  of  thirty- 
nine  children  vaccinated  with  the  Passy  lymph,  then  three  or 
four  years  old,  or  with  lymph  of  the  original  stock,  forty  years 
old  or  more,  only  one  had  a  papular  eruption.  (Traite  sur  la 
Vaccine,  p.  552.)  But  this  does  not  pertain  to  all  stocks  of 
lymph.  Jenner  does  not  appear  to  have  found  these  second- 
ary eruptions  more  frequent  in  his  earlier  than  in  his  subse- 
quent vaccinations. 


104  HANDBOOK  OF   VACCINATION. 

than  those  produced  by  ordinary  lymph.  Desiccation 
is  generally  prolonged,  being  often  for  some  clays 
limited  to  the  center.  When  the  vesicle  is  neither 
ruptured,  nor  spontaneously  bursts,  the  crust  is  often 
retained  to  the  fourth  or  fifth  week,  bringing  away  with 
it  a  circle  of  the  corium,  often  the  whole  depth  of  it,  and 
some  of  the  subjacent  connective  tissue.  A  deep  fove- 
ated  red  cicatrix  is  left,  or  there  is  a  yellow  foul  ex- 
cavation which  ultimately  furnishes  the  pink,  shining, 
puckered  aspect  of  a  small-pox  scar.  Often,  however, 
the  vesicles  burst  or  get  broken  at  the  time  of  the 
height,  or  about  the  decline,  of  the  areola;  and  when 
this  occurs  in  strumous  or  irritable  subjects,  secondary 
inflammation  may  be  set  up,  with  sloughing,  abscesses 
in  the  cellular  membrane  and  axillary  glands,  and  pro- 
portionate constitutional  irritation — mischief  which, 
however,  generally  soon  subsides. 

Progress  of  humanization  of  lymph. — Transmission 
of  the  lymph  from  subjects  directly  infected  from  the 
cow,  through  two,  three,  or  more  children  successively, 
diminishes  the  severity  of  the  local  symptoms;  and  the 
vesicles  then  acquire  increased  size  and  beauty.  In 
succeeding  removes,  varieties  of  appearance  will,  as  in 
ordinary  vaccinations,  depend  much  on  variety  of  sub- 
jects, vaccination  with  the  same  lymph  producing  in 
some  finer,  in  others  smaller  vesicles,  the  latter  being 
often  accompanied  with  more  intensity  of  constitutional 
symptoms  than  the  former. 

Varieties  in  amount  of  constitutional  disturbance. — 
As  regards,  indeed,  the  general  or  constitutional  dis- 
turbance of  subjects  vaccinated  by  primary  cow- 
lymph,  or  its  early  removes,  the  greatest  variety  ex- 
ists ;  roseola  or  lichen,  with  vomiting,  diarrhoea,  deli- 


COW-POX  IN  THE  HUMAN  SUBJECT.        105 

rittm,  etc.,  arising  in  some  subjects,  while  in  others 
mere  acceleration  of  pulse  is  observed,  without  com- 
plaint; a  single  vesicle  in  some  being  attended  with 
earlier,  more  severe,  and  longer  protracted  symptoms 
than  four  or  six  will  produce  in  others.  "  Although," 
says  Ceely,  whose  description  of  the  effects  of  primary 
cow-lymph  I  have  closely  followed,  "the  greater  part 
of  my  experiments  with  primary  lymph  and  its  early 
removes  have  exhibited  the  above  as  its  qualities  and 
accidents,  I  think  it  not  improbable  that  primary  lymph 
may  vary  in  these  respects,  and  be  modified  by  season 
and  other  circumstances,  both  individual  and  local."* 
Of  the  truth  of  this  observation  I  apprehend  there  can 
be  no  doubt  The  primary  lymph,  discovered  at  Passy 
in  1836,  which  was  the  subject  of  M.  Bousquet's  ex- 
periments, appears  to  have  developed  generally  phe- 
nomena closely  corresponding  to  Ceely's  description, 
as  (1)  the  reddish  blush  immediately  succeeding  the 
operation,  and  passing  gradually  into  papule ;  (2)  the 
size,  long  duration,  and  hardness  of  the  areola;  (3)  the 
prolongation  of  the  stage  of  desiccation;  and  (4)  the 
long  retention  of  the  crust,  f  The  lymph-stock  which 
Mr.  Estlin  set  on  foot  from  the  cow,  in  1836,  developed 
for  some  time,  during  its  early  transmissions,  very  ac- 
tive local  and  constitutional  phenomena;  much  care  was 
required  in  its  use,  deep  ulceration  and  glandular  ab- 
scesses otherwise  sometimes  resulting.  But,  in  the 
accounts  we  have  of  many  other  stocks,  we  are  far  from 
finding  that  the  same  activity  of  symptoms  has  always 

*  See  Ceely's  admirable  and  oft-quoted  Memoir,  Trans. 
Prov.  Med.  and  Surg.  Assoc.,  vol.  viii.  pp.  342-352. 
f  Nouveau  Traite,  etc.,  p.  403,  seq. 
10 


106  HANDBOOK  OF  VACCINATION. 

been  manifested,  or  that  specialties  have  continued 
through  so  many  removes.  The  primary  lymph  of 
some  stocks,  indeed,  has  been  found  to  produce  results 
differing  in  no  respect  from  those  of  an  ordinary  vac- 
cination. More  generally,  there  has  been  some  retard- 
ation of  progress,  and  some  manifestation  of  unusual 
local  or  constitutional  activity,  at  all  events  for  a  trans- 
mission or  two ;  the  phenomena,  after  two  or  three  re- 
moves, being  the  same  as  those  observed  where  human- 
ized lymph  has  been  employed.*  The  difficulty  in 
getting  the  lymph  to  take  until  it  has  become  human- 
ized is  always  experienced. 

43.  Symptoms,  etc.  of  the  Casual  Cow-pox  of 
Milkers. — In  milkers  who  contract  cow-pox  casually 
the  severity  of  the  local  and  general  symptoms  is  often 
much  greater  than  in  subjects  in  whom  vaccination 
with  primary  cow-lymph  has  been  designedly  per- 
formed. This  is  due  (1)  to  the  constant  movement  to 
which  the  vesicles,  from  their  position  on  the  hands, 
etc.,  are  generally  subject,  and  (2)  to  their  frequent 
rupture,  with  consequent  reiterated  applications  of 
lymph.  Hence  there  are  not  infrequently  deep  slough- 
ing of  the  skin  and  connective  tissue,  and  ulcerations 
slow  to  heal.  Ceely  has  met  with  instances  in  which, 
probably  either  from  an  insufficient  application  of 
lymph,  or  a  local  or  constitutional  indisposition  to  re- 
ceive the  disease  in  the  usual  way,  the  vesicles  on 
milkers  have  been  imperfectly  developed,  with  little  or 
no   obvious    constitutional   disturbance,   exhibiting   a 

*  See  Hering,  Ueber  Kuhpocken  an  Kvihen ;  Kapport  sur 
les  Vaccin.  pratiquees  en  France  pendant  1841 ;  and  Sixth 
Keport  of  Medical  Officer  of  the  Privy  Council,  p.  10. 


COW-POX  IN  THE  HUMAN  SUBJECT.        10? 

marked  contrast  to  the  local  or  general  effects  on  other 
individuals  affected  at  the  same  time  from  the  same 
source ;  and  some  such  cases  he  has  seen  suffer  after- 
ward from  unquestionable  though  mild  small-pox.  It 
is  not  only,  therefore,  where  milkers  have  mistaken 
spurious  for  real  cow-pox,  that  they  are  liable  to  be 
deceived  as  to  their  protection  against  small-pox.  They 
may  continue  subject  to  that  disease,  according  to 
Ceely's  observations,  after  infection  from  cows  affected 
with  real  cow-pox,  if  their  infection  has  been  "at  a  late 
period  of  the  disease  with  deteriorated  and  purulent 
virus,  or  even  with  perfect  lymph  of  which  they  had 
not  at  the  time  been  sufficiently  susceptible."*  The 
casual  cow-pox  in  man  and  its  early  removes  are  of 
course  liable  to  be  attended  occasionally  with  the  same 
papular  and  vesicular  eruptions  as  have  been  described 
as  occurring  sometimes  in  the  course  of  vaccination 
with  primary  cow-lymph  (§  42). 

44.  Vaccination  with  Variola-vaccine  Lymph. — It 
is  impossible  to  read  Ceely's  careful  and  most  interest- 
ing accountf  of  the  phenomena  exhibited  by  human 
subjects  vaccinated  by  him  with  the  lymph  generated 
by  the  variolation  of  the  cow,  without  recognizing  that 
we  are  reading  over  again  the  whole  story  of  the  in- 
oculation of  the  human  subject  with  primary  cow- 
lymph.  In  the  children  and  others  inoculated  with 
the  variola-vaccine  lymph,  either  direct  or  in  its  ear- 
liest removes,  there  was  the  same  difficulty  in  making 
the  vaccination  take,  the  same  occasional  occurrence  of 
imperfect  results,  the  same  retardation  in  successful 
cases  of  the  papular  and  subsequent  stages,  and  the 

*  Ceely,  op.  cit,  p.  336.  f  °P-  cit->  PP-  412-420. 


108  HANDBOOK  OF   VACCINATION. 

same  activity  of  local  symptoms  as  are  noticed  when 
primary  cow-lymph  is  used.  The  small  supernumerary 
vesicles  round  the  vaccinated  spots,  within  the  sphere 
of  the  areola,  were  also  noticed  in  particular  cases ;  and 
in  four  cases  a  supernumerary  vesicle  or  two  was  de- 
veloped elsewhere.  The  constitutional  symptoms  were 
well  marked  and  in  some  cases  severe,  but  pertained 
only  to  the  secondary  or  developed  state  of  the  disease, 
and  were  scarcely  noticeable  until  the  vesicles  had  at- 
tained the  stage  of  areola, — just  as,  with  primary  cow- 
lymph,  the  vesicles  improved  in  appearance  by  passing 
through  two  or  three  subjects,  and  attained  then,  and 
retained,  a  state  of  great  beauty  and  perfection. 
Roseola,  strophulus,  and  lichen  were  seen  in  some  of 
the  subjects ;  the  papules  in  a  few  instances  became 
vesicular.  In  one  infant,  six  months  old,  vaccinated 
at  the  sixth  remove,  an  eruption  of  strophulus  became 
vesiculated  at  its  summit  to  an  extraordinary  degree, 
disappearing  and  reappearing  for  three  weeks;  in 
another  infant,  aged  fifteen  months,  six  days  after  vac- 
cination at  the  sixth  remove,  an  eruption  of  vesicular 
varicella  (which  disease  was  prevailing  in  the  village 
at  the  time)  appeared,  and  retarded  the  progress  of  the 
vaccination  for  a  couple  of  days.  But  no  eruption  with 
the  slightest  approach  to  varioloid  was  seen  ;  and  the 
only  other  sort  of  eruption  noticed  than  those  above 
stated  was,  in  a  few  instances,  "a  vesicular  eruption  of  a 
pemphigoid  character,  either  in  large  bullae  or  closely 
resembling  lenticular  varicella."*     And,  just  as  when 

*  This  eruption  is  strictly  one  of  the  attendant  vaccinal 
eruptions.  It  may  be  seen  on  the  cow,  and  often  on  young 
dogs,  during  the  progress  of  vaccination.     In  young  children 


COW-POX  IN  THE  HUMAN  SUBJECT.        109 

primary  cow-lymph  is  used,  the  attendant  vaccine 
eruptions,  when  they  did  occur,  were  limited  almost 
exclusively  to  young  children. 

45.  Vaccination  with  Secondary,  or  Inoculated 
Cow-lymph;  Animal  Vaccination.  —  When  primary 
cow-lymph  is  first  passed  by  inoculation  through  a 
succession  of  animals  and  then  transplanted  to  the 
human  subject,  the  effects  it  produces  depend  partly  on 
the  properties  of  the  parent  stock,  and  partly  on  the 
number  of  artificial  transmissions  it  has  undergone. 
Lymph  of  a  very  active  kind,  which  had  been  obtained 
from  the  natural  disease  in  a  cow  at  Beaugency,  in 
1866,  and  which,  after  being  passed  through  three 
animals,  was  used  for  vaccinating  children  at  the 
Academie  de  Medecine  at  Paris  (in  the  performance 
of  what  has  been  termed  "Animal  Vaccination"),  still 
manifested  the  active  and  virulent  symptoms  which 
attend,  as  we  have  seen,  the  use  of  some  stocks  of 
primary  cow-lymph.  The  vesicles  it  produced  on  chil- 
dren were  even  said  to  be  nearly  double  the  size  of 
those  resulting  from  the  first  removes  of  the  Passy 
lymph,  and  the  inflammatory  effects  to  be  so  exceed- 
ingly severe  that  M.  Bousquet,  on  seeing  the  cases, 
judiciously  recommended  one  of  the  members  of  the 
Academie,  who  was  about  to  take  some  of  this  lymph 
for  use  in  his  own  practice,  to  wait  till  it  had  under- 

it  may  subside  in  a  few  days  or  may  continue  for  some  weeks. 
Ceely  (Trans.  Prov.  Med.  and  Surg.  Assoc.,  vol.  x.  p.  231) 
narrates  a  case  in  a  child,  eight  months  old,  vaccinated  with 
lymph  eighty  removes  from  the  cow,  in  which  it  appeared 
and  lasted  five  or  six  weeks;  and  Mr.  Farish,  of  Cambridge, 
also  narrates  a  considerably  protracted  case.  (See  Willan  on 
Vaccine  Inoculation.) 

10* 


110  HANDBOOK  OF   VACCINATION. 

gone  further  transmissions.*  But  with  further  tran- 
sits through  animals  these  peculiar  effects  appear  to 
have  subsided;  and  when  lymph  of  this  stock,  con- 
tinued through  animals  and  taken  from  an  animal  later 
in  the  series,  was  sent  to  Brussels  and  there  employed, 
its  effects  resembled  more  those  of  an  ordinary  vaccina- 
tion. Tried  side  by  side,  by  a  Commission  of  the  Bel- 
gian Academie,  with  some  Jennerian  lymph  which 
they  had  in  use,  the  only  difference  noted  was  that 
the  vesicles  it  produced  were  a  little  bigger  {tin  peu 
plus  larges):f  but,  like  Ceely's  and  some  other  pri- 
mary lymphs,  it  was  found  to  improve  by  a  few  tran- 
sits through  the  human  subject.  When  some  of  it 
thus  humanized,  and  some  of  it  continued  through 
animals,  were  used  in  the  vaccination  of  the  same  sub- 

*  Gazette  Medicale,  1866,  p.  319. 

f  Bulletin  de  l'Academie,  tome  xxxii.  According  to  M.  de 
Paul,  not  only  the  vesicles  produced  by  this  lymph,  but  also 
the  vesicles  produced  by  retro-vaccine  lymph  which  had  un- 
dergone a  number  of  transits  through  animals  (p.  27,  note), 
when  compared  at  the  Academie  with  the  vesicles  produced 
by  the  humanized  lymph  there  in  use,  were  found  to  be  very 
much  finer  and  larger.  But  if  so,  the  stock  of  the  Academie 
must  have  differed  in  its  effects  from  the  Jennerian  stock  in 
use  in  Brussels.  In  these  comparisons  everything,  in  fact, 
depends  on  the  stocks  with  which  the  comparison  is  instituted 
— whether  they  have  or  have  not  lost  any  of  their  essential 
properties  (see  Chap.  X.,  On  the  Alleged  Degeneration  of 
Lymph,  which  should  be  read  along  with  this  Section).  Let 
it  be  well  understood,  however,  that  I  am  far  from  thinking 
the  size  of  the  vesicle  an  essential  quality  ;  any  one  has  only 
to  look  at  Jenner's  plates  to  see  that  it  is  nothing  of  the  sort. 
It  is  the  character  and  course  that  must  be  looked  to;  and  a 
vesicle  is  not  to  be  condemned  on  account  of  its  size,  unless  it 
is  also  puny  and  inactive. 


COW-POX  IN  THE  HUMAN  subject,       m 

jects,  the  vesicles  of  the  humanized  lymph  were  mani- 
festly the  finer  and  better  developed.  The  course  of 
vaccination  of  the  human  subject  with  inoculated  cow- 
lymph  (animal  vaccination)  is  frequently  retarded. 
Vaccination  thus  performed  is  much  less  successful 
than  vaccination  with  humanized  lymph.* 

*  Well  aware  of  the  difficulties  frequently  attending  the 
transplantation  to  the  human  subject  of  primary  cow-lymph, 
or  of  retro-vaccine  lymph.  I  saw,  certainly  with  surprise,  the 
statement  of  M.  de  Paul  and  others  that  the  inoculated  cow- 
lymph  (animal  vaccination)  was  more  successful  in  the  per- 
formance of  human  vaccinations  than  humanized  lymph  from 
arm  to  arm ;  and  this  surprise  was  greatly  increased  on  ex- 
amination of  the  facts  on  which  the  statement  was  based,  viz., 
the  results  of  the  animal  vaccinations  of  M.  Husson  and  at  the 
Academic  A  good  vaccinator,  it  may  be  premised,  vaccina- 
ting from  arm  to  arm  with  humanized  lymph,  does  not  fail  to 
infect  above  once  in  150  operations  (see  \  69).  Now  from  the 
largest  series  of  observations  which  we  have  of  animal  vac- 
cinations, that  of  M.  Husson,  it  appears  that  of  4163  vaccina- 
tions of  children  (I  exclude,  of  course,  all  cases  of  revaccina- 
tion)  he  was  successful  in  2614,  or  62-79  per  cent.,  was  un- 
successful in  949,  or  22-80  per  cent.,  600  of  the  cases  not  having 
been  inspected.  But  this  result,  confessedly  unsatisfactory, 
is  considered  to  be  in  some  measure  explained  by  M.  Husson 
having  been  obliged  (from  the  limited  number  of  animals  at 
his  command)  to  perform  many  of  the  operations  with  lymph 
taken  from  the  animal  after  the  sixth  day  of  the  vaccine  in- 
fection, and  when  it  had  become  comparatively  inert.  The 
vaccinations  at  the  Academic  were  681,  but  by  eliminating 
275  of  these  cases,  or  40  per  cent,  of  the  whole,  as  being  ea*es 
in  which  it  is  said  the  vaccination  had  either  also  been  done 
with  late  lymph,  or  with  lymph  from  heifers  who  were  in  ill- 
health  (genisses  maladcs),  [it  is  not  explained  why  in  this 
large  proportion  of  cases  the  vaccination  had  been  done  in 
this  objectionable  way,  or  from  these  objectionable  sources,] 


112  HANDBOOK  OF   VACCINATION. 

46.  Vaccination  with  Retro-vaccine  Lymph. — 
When  active  lymph,  such  as  passes  from  arm  to 
arm  with  the  greatest  facility,  is  passed  through  the 
cow  (§  12,  c)  and  at  once  vaccinated  back,  it  jetretains 
so  much  of  its  humanization  that  it  is  not  apt  to  fail 
like  primary  cow-lympb,  but  will  be  found  also  to  have 
lost  so  much  of  its  humanization  that  on  its  return  to 
the  human  subject  it  takes  effect  less  kindly :  papula- 
tion is  usually  retarded,  and  though  the  vaccination 
may  attain  maturity  at  the  ordinary  average  period, 
the  completion  of  the  maturation  is  often  postponed. 
The  vesicles  are  often  smaller  and  the  disease  not 
really  so  well  developed  as  by  the  stock  from  which  the 
lymph  was  derived.  Two,  three,  four,  or  several  re- 
moves are  necessary  to  give  it  the  same  activity  as  it 
had  before  it  was  transferred. 

it  was  found  that,  out  of  the  remaining  406  cases,  the  opera- 
tion had  been  successful  on  278,  or  upwards  of  68  per  cent., 
and  unsuccessful  on  five  only,  or  1-2  per  cent.  But,  as  in  no 
fewer  than  123  cases,  or  30  per  cent.,  the  result  was  not  ascer- 
tained, the  utter  worthlessness  of  these  observations  to  determ- 
ine the  real  effects  of  a  new  mode  of  proceeding  is  obvious.  If 
any  satisfactory  conclusions  at  all  are  to  be  come  to,  it  can 
only  be  done  by  taking  two  or  three  hundred  cases,  and  follow- 
ing them  completely  out ;  it  is  very  singular  that  this  course, 
so  properly  recommended  by  M.  Guerin,  should  not  have  been 
pursued.  Of  988  animal  vaccinations,  performed  on  babies  at 
La  Pitie  by  M.  Empis,  the  results  were  observed  in  all  but 
fifty-eight  cases,  and  they  gave  558  successes  to  372  failures. 
The  vaccinations  watched  by  the  Commission  in  Brussels  ap- 
pear to  have  been  made  with  great  care  and  with  unusual 
success,  but  they  were  far  too  few  in  number  for  safe  conclu- 
sions. But,  even  in  them,  in  the  first  series  of  twenty-four 
(inspected)  cases,  there  were  but  104  vesicles  for  144  inser- 
tions— a  number  far  short  of  that  obtainable  with  good  human- 
ized lymph. 


COW-POX  IN  THE  HUMAN  SUBJECT.        113 


(B)  COUKSE  OF  COW-POJ  IN  PERSONS  WHO  HAVE 
ALREADY  BEEN  INFECTED  BY  IT. 

47.  Phenomena  and  Course  of  Revaccination. — In 
the  majority  of  persons  the  regular  phenomena  of  vac- 
cination, such  as  have  been  above  described,  can  only 
be  produced  once  in  the  lifetime ;  any  subsequent  in- 
troduction of  vaccine  lymph  either  failing  to  produce 
any  local  effect  whatever,  or  (much  more- commonly) 
producing  a  modified  effect,  resembling  one  of  the  forms 
of  spurious  vaccination.  The  absence  of  effect  is  rela- 
tively most  common  in  the  child,  the  spurious  effect 
most  common  in  the  adolescent  and  adult.  This  spu- 
rious effect  consists  either  in  a  papule,  or  (more  often) 
in  an  acuminated  vesicle,  with  a  hard  and  irregular 
areola.  The  symptoms  begin  early,  reach  their  height 
by  the  fifth  or  sixth  day,  and  then  decline.  The  scab, 
small  and  imperfect,  forms  generally  on  the  eighth  day, 
and  soon  falls.  There  is  usually  much  itching,  and 
often  considerable  constitutional  irritation.  Severe 
constitutional  symptoms  are,  out  of  all  proportion, 
more  frecpaent  in  revaccination  than  in  primary  vac- 
cination ;  and  in  very  exceptional  cases  the  vaccine 
lymph  may  act  as  an  animal  poison,  giving  rise  to 
phlegmonous  erysipelas ;  some  still  rarer  cases  have 
occurred  of  pyaemia,  terminating  fatally.  In  a  certain 
proportion  of  cases,  the  results  of  revaccination  are 
the  same  as  those  of  primary  vaccination,  the  vesicle 
in  shape  and  character  being  in  no  degree  distinguish- 
able ;  in  such  cases  the  areola  is  sometimes  small  and 
transitory,  and  the  scab  on  falling  leaves  a  small  and 
poor  cicatrix ;  at  other  times  the  areola  is  perfect,  and 


114  IIANDBOOK  OF   VACCINATION. 

a  good  cicatrix  is  left.  Normal  vesicles  resulting  from 
revaccination  are  much  more  frequent  in  adults  than 
in  children,  but  I  have  seen  them  on  the  arms  of  chil- 
dren a  few  years  old,  who  had  excellent  marks  of  their 
first  vaccination. 

(C)  TKEATMENT  OF  VACCINATION. 

48.  Treatment  of  Vaccination. — The  ordinary  symp- 
toms of  cow-pox  seldom  call  for  any  treatment,  general 
or  local.  If  the  child  be  feverish,  a  little  castor  oil,  or 
magnesia,  or  powder  of  jalap,  or  of  calomel  and  jalap, 
may  be  given  with  advantage :  if  the  arm  be  more 
than  usually  inflamed,  a  dressing  of  tepid  water  with 
oil  silk  or  tepid  lead-lotion  may  be  employed.  A  simple 
cooling  treatment  is  enough  to  meet  any  cases  of  vac- 
cine lichen  or  roseola.  If  the  vesicles  should  degene- 
rate or  ulcerate,  the  sores  may  be  dressed  with  oxide 
of  zinc  ointment,  and  the  general  health  may  require 
to  be  looked  to.  If  erythema  or  erysipelas  should 
occur,  the  treatment  would  be  the  same  as  that  of  ery- 
thema or  erysipelas  arising  from  any  other  cause. 


OF   VACCINATING.  115 


CHAPTER    VI. 

OF   VACCINATING. 

49.  Origin  of  the  term  Vaccination. — The  terms 
"Vaccination"  and  "to  Vaccinate,"  to  signify  the  in- 
oculation of  the  cow-pox,  were  first  introduced  by 
Dunning  ;*  and  their  convenience  was  at  once  recog- 
nized. They  are  the  terms  now  exclusively  employed 
for  the  purpose  in  medical  writings,  in  the  conversation 
of  the  educated,  and  among  the  common  people  also 
in  the  greater  part  of  England ;  but  there  are  still  parts 
of  the  kingdom  in  which  the  lower  orders  seem  never 
to  have  heard  of  vaccination,  though  they  are  quite 
familiar  with  the  process  of  being  "cut  for  the  cow- 
pock." 

50.  Things  to  be  attended  to  in  Vaccinating. — In 
conducting  vaccination  special  attention  must  be  given 
(a)  to  the  state  of  the  person  to  be  vaccinated,  (6)  to 
the  selection  of  the  lymph  to  be  used  in  the  vaccina- 
tion, and  (c)  to  the  thorough  insertion  of  the  lymph. 

(a)  State  of  the  Individual  to  be  Vaccinated :  (1) 
Health. — Except  for  pressing  reasons,  persons  should 
only  be  vaccinated  when  they  are  in  good  health.  By 
this  is  not  meant  that  they  need  always  be  robust  at 
the  time  of  vaccination,  but  simply  that  they  should  be 
free  from  any  acute  disease,  or  from  any  chronic  disease 
which  is  known  to  interfere  with  the  regular  course  of 

*  Baron's  Life  of  Jenner,  vol.  ii.  p.  336. 


116  HANDBOOK  OF   VACCINATION. 

the  vaccine  vesicle.  There  are  many  diseases  which 
do  not  interfere  at  all  with  the  course  of  vaccination. 
Cline's  famous  first  vaccination  was  in  a  lad  who  had 
disease  of  the  hip-joint :  it  is  well  known  that  scrofula 
and  syphilis  do  not  prevent  the  system  receiving  the 
vaccine  influence  in  the  normal  way :  and  one  would 
never  hesitate  to  vaccinate  a  child,  whose  general  con- 
dition was  fair,  merely  because  it  was  going  through 
the  chronic  stage  of  hooping-cough.  The  diseases 
which  most  decidedly  contraindicate  vaccination  are 
(besides  acute  febrile  diseases)  diarrhoea  and  cutaneous 
diseases,  especially  cutaneous  diseases  of  the  vesicular 
type,  as  herpes,  eczema,  and  intertrigo.  Jenner 
throughout  his  writings  insists  strongly,  and  with 
frequent  iteration,  on  the  extent  to  which  herpes  may 
interfere  with  the  regular  course  of  the  vaccine  vesicle  ;* 
and  that  very  simple  disease,  intertrigo,  so  often  modi- 
fies, or  even  completely  spoils,  the  course  of  vaccina- 
tion, that  it  is  a  precaution  which  should  never  be 
neglected  by  a  vaccinator,  to  look  well  whether  there 
be  any  chafing  behind  the  ears,  in  the  folds  of  the 
neck,  or  in  the  groins,  before  he  proceeds  to  vaccinate 
a  child  (§  36,  c).  But  other  cutaneous  diseases  of  the 
non-vesicular  kind,  such  as  strophulus  and  lichen,  have 
been  observed  to  interfere  with  the  full  and  correct 
reception  of  the  vaccine  influence,  and  Jenner's  own 

*  The  same  diseases  were  found  to  interfere  with  the  regu- 
lar progress  of  variolous  inoculation.  "The  most  ample  tes- 
timonies," says  Jenner,  M  lie  before  me  that  the  herpetic  and 
some  other  irritative  eruptions  are  capable  of  rendering  vario- 
lous inoculation  imperfect,  as  well  as  the  vaccine."  (See  his 
tract  on  the  Varieties  and  Modifications  of  the  Vaccine  Pus- 
tule.) 


OF   VACCINATING.  117 

rule,  "  to  sweep  away  all  eruptions  from  the  skin  pre- 
vious to  inserting  the  vaccine  lymph,"  should  never, 
under  ordinary  circumstances,  be  departed  from.*  It 
is  nothing  to  the  point  that  children  suffering  from 
these  and  other  forms  of  eruption  have  been  frequently 
vaccinated  with  perfect  success  and  the  utmost  regu- 
larity of  vesicle.  Undoubtedly  this  is  so  :f  but  fre- 
quently also  it  is  not  the  case,  and  the  careful  and 
conscientious  vaccinator  looks  always  to  the  making 
his  success  as  certain  as  possible,  and  scrupulously 
avoids  anything  of  a  hap-hazard  kind.  In  laying  down 
these  rules,  however,  so  positively,  as  to  the  health  of 
a  person  in  whom  vaccination  is  to  be  performed,  it  is 
always  assumed  that  the  patient  is  not  in  any  imme- 
diate risk  of  small-pox ;  for,  when  this  is  the  case,  it 
would  be  foolish  in  the  extreme  to  hesitate  or  to  wait. 
However  much,  under  other  circumstances,  we  should 
have  preferred  that  the  patient  should  be  in  a  better 
state  of  health,  nothing  but  the  actual  presence  of  acute 
febrile  disease  of  a  serious  character  would  then  be  a 
sufficient  contraindication. 

(2)  Age.  —  Health  permitting,  vaccination  should 
always  be  performed  in  very  early  infancy.  Young 
children,  unvaccinated,  are  the  chief  sufferers  from 
small-pox.  About  one-fourth  of  all  the  mortality  which 
arises  from  that  fatal  disease  in  England,  takes  place 
in  children  under  the  age  of  one  year.  In  Scotland, 
where,  until  the  passing  of  the  recent  excellent  Yaccin- 

*  On  the  Influence  of  Artificial  Eruptions  in  certain  Dis- 
eases.    4to.  Lond.  1822. 

■f-  As  "Willan  justly  observes,  "  The  effect  of  cutaneous  erup- 
tions on  the  vaccine  vesicle  in  frequent,  not  universal."  (On 
Vaccine  Inoculation,  p.  40,  note.) 

11 


118  HANDBOOK  OF   VACCINATION. 

ation  Act,  infantile  vaccination  was  much  more  neg- 
lected than  in  England,  the  proportion  even  amounted 
to  thirty  per  cent.;  and  of  the  deaths  under  one  year, 
nearly  one-fourth  were  under  the  age  of  three  months. 
The  great  risk  of  delay  is  therefore  obvious.  This 
risk  is  by  far  the  greatest  in  large  towns,  because 
from  them  small-pox  is  seldom  absent  at  any  time, 
and  never  absent  for  any  long  period  together.  Plump 
and  healthy  children  living  in  such  towns  should  be 
vaccinated  when  a  month  or  six  weeks  old;*  in  more 
delicate  children  the  vaccination  might  be  postponed 
till  they  are  two  or  three  months  old,  but  all  whose 
health  does  not  offer  some  positive  contraindication 
should  be  vaccinated  by  the  age  of  three  months. 
This  early  period  of  life  is  also  particularly  suitable 
for  vaccination,  as  being  usually  free  from  the  disturb- 
ing influence  of  teething :  it  is  therefore  on  every  ac- 
count to  be  preferred.  Circumstances  connected  with 
lymph-supply  render  a  longer  delay  unavoidable,  in 
many  instances,  in  small  towns  and  rural  districts; 
and,  when  small-pox  is  not  present  in  the  localities, 
such  delay,  if  not  .too  long  continued,  is  not  of  material 
moment.  But  even  children  living  in  such  districts 
should  always  be  vaccinated  within  a  few  months,  six 
or  seven  at  the  utmost,  from  birth. 

*  My  opportunities  of  watching  vaccination  at  this  age  have 
been  considerable,  and  enable  me  strongly  to  recommend  it 
when  the  children  are  well  and  plump.  They  take  as  surely, 
have  vesicles  quite  as  fine,  and  go  through  the  disease  as  regu- 
larly, as  do  children  vaccinated  some  weeks  older.  The  early, 
and  all  subsequent,  Instructions  of  the  National  Vaccine  Es- 
tablishment recommend  six  weeks  as  the  best  age,  except  when 
children  are  delicate,  or  suffering  from  disease. 


OF   VACCINATING.  119 

(3)  Circumstances  which  call  for  the  immediate 
performance  of  Vaccination. — While  the  periods  above 
stated  should  not,  except  for  special  reasons  in  indi- 
vidual cases,  be  exceeded,  it  may  often  be  prudent,  and 
even  indispensable,  to  perform  vaccination  at  a  much 
earlier  age.  The  danger  of  delay  is  always,  of  course, 
in  direct  relation  to  the  exposure,  or  liability  to  expo- 
sure, to  the  infection  of  small-pox  ;  and  when  this  dis- 
ease is  prevailing  in  a  locality,  every  parent  who  has 
an  unvaccinated  child,  however  young,  should  be  anx- 
ious and  watchful  until  he  has  secured  its  protection. 
When  small-pox  is  in  the  family  or  house,  no  age  must 
be  considered  too  early  for  vaccination ;  repeatedly, 
under  such  circumstances,  have  infants  been  vaccin- 
ated immediately  after  birth,  and  saved  thereby  from 
the  disease ;  repeatedly,  for  want  of  like  precaution, 
have  their  lives  been  sacrificed.  Vaccination  at  this 
early  age  is  certainly  as  safe,  and  appears  to  be  also 
generally  as  successful,  as  in  older  infants.* 

No  question  in  medical  practice  may  be  regarded  as 
more  completely  settled  than  the  course  which  a  prac- 
titioner should  take  when  there  are  persons  of  any 
age  whatever,  unvaccinated  or  not  otherwise  protected 
against  small-pox,  in  a  house  or  family  in  which  that 
disease  breaks  out.  At  once,  and  without  any  delay, 
the  vaccination  of  all  such  persons  should  be  performed : 

*  See  "Bapport  de  l'Acad.  Imp.  de  Med.  sur  les  Vaccina- 
tions," etc.  18G0,  where  a  large  number  of  facts  are  brought 
together,  from  maternities  and  the  practice  of  large  vaccina- 
tors, illustrative  of  this  point.  It  is  only,  however,  where 
there  is  immediate  exposure  to  small-pox  infection  that  vac- 
cination within  the  first  few  days  from  birth  is  necessary,  or 
is  at  all  likely,  I  apprehend,  to  be  practiced. 


120  HANDBOOK  OF   VACCINATION. 

the  loss  of  a  clay  may  be  the  sacrifice  of  a  life.  It  docs 
not  follow  that  because  a  person  has  been  exposed  to 
the  infection  of  small-pox,  he  has  therefore  received 
the  infection,  and  the  vaccination  may  be  in  time  to 
prevent  the  disease  altogether ;  but,  supposing  that 
before  the  vaccination  is  performed  the  variolous  in- 
fection has  actually  been  taken  up  by  the  system  (of 
which,  of  course,  during  the  stage  of  incubation  we 
can  know  nothing),  unless  that  infection  have  so  far 
got  the  start  that  the  small-pox  symptoms  appear 
before  the  vaccination  reaches  the  stage  of  developed 
areola,  the  vaccine  process  will  still  either  prevent  or 
modify  the  small-pox  eruption ;  if,  on  the  other  hand, 
the  variola  manifest  itself  before  the  vaccination  has 
reached  its  protective  stage,  its  stage  of  areola,  the 
vaccination,  though  it  will  have  done  no  good,  will 
most  certainly  have  done  no  harm — the  small-pox  will 
simply  go  on  as  though  it  had  never  been  performed. 
Now,  whether  the  vaccination  shall  reach  the  stage  of 
areola  or  not  before  the  small-pox  appears,  depends 
entirely  on  the  length  of  time  which  had  elapsed  be- 
tween the  reception  by  the  system  of  the  variolous 
poison  and  the  performance  of  the  vaccination.  As 
the  incubative  period  of  small-pox  is  twelve  days, 
while  the  time  requisite  to  bring  vaccination  to  the 
stage  of  areola  is  only  nine  days,  vaccination  performed 
any  time  within  the  first  three  days  will  reach  areola 
soon  enough  to  produce  its  protective  power ;  after 
this,  whatever  the  local  success  of  the  vaccination,  no 
constitutional  protection  will  be  imparted.* 

*  "  Suppose  an  un vaccinated  person  to  inhale  the  germ  of 
variola  on  a  Monday ;  if  he  be  vaccinated  as  late  as  the  follow- 


OF  VACCINATING.  121 

If  there  were  only  any  means  of  ascertaining  whether 
a  person  exposed  to  small-pox  infection  had  actually 
received  it,  and  if  so,  at  what  moment  this  had  taken 
place,  we  should  know  exactly  whether  it  were  worth 
while  to  vaccinate  or  not ;  but  as  no  such  means  exist, 
the  obvious  rule  of  practice  is  to  assume  that  the  poison 
has  not  been  inhaled,  or  has  only  recently  been  inhaled, 
and  to  give  our  patient  the  chance.  But  no  prudent 
practitioner,  vaccinating  under  these  circumstances, 
will  commit  himself  as  to  the  protective  value  of  his 
vaccination  until  he  sees  the  areola  completely  formed. 

For  want  of  knowledge  or  of  consideration  of  these 
simple  facts,  practitioners  have  repeatedly  compromised 
their  credit,  many  lives  have  been  lost  that  should  have 
been  saved,  and  erroneous  entries  are  daily  made  in 
our  death  registers.  Seeing  perfect  vaccine  vesicles 
on  the  eighth  day,  the  practitioner  who  was  not  aware 
of  the  necessity  of  waiting  for  areola  has  promised 
safety,  and  been  cruelly  disappointed :  his  credit  and 
the  credit  of  vaccination  have  equally  suffered.  The 
occurrence  of  three  or  four  cases  together  of  unmodified, 
and  perhaps  fatal,  small-pox  in  persons  having  well- 
formed  and  complete  vaccine  vesicles  on  their  arms, 
has  at  times  led  the  practitioner,  not  to  the  true  ex- 

ing  Wednesday,  the  vaccination  will  be  in  time  to  prevent 
small-pox  being  developed  ;  if  it  be  put  off  until  Thursday, 
tho  small-pox  will  appear,  but  will  be  modified ;  if  the  vac- 
cination be  delayed  until  Friday,  it  will  be  of  no  use,  it  will 
not  have  had  time  to  reach  the  stage  of  areola,  the  index  of 
safety,  before  the  illness  of  small-pox  begins  ;  this  we  have 
seen  over  and  over  again,  and  know  it  to  be  the  exact  state  of 
the  question."  (Marson,art.  "  Small-pox,"  in  System  of  Med- 
icine, op.  cit.,  vol.  i.  p.  477.) 

11* 


122  HANDBOOK  OF   VACCINATION. 

planation,  viz  ,  that  his  vaccination  in  these  cases  had 
been  too  late,  but  to  the  notion  that  vaccination  was 
always  useless  when  small-pox  was  incubating,  and 
even  to  the  absurd  and  totally  unfounded  supposition 
that  it  might  increase  the  danger :  so  he  has  shut  up 
his  vaccine  lancet,  and  children  have  been  allowed  to 
perish  from  non-performance  of  vaccination,  whose 
deaths  were  clearly  chargeable  to  his  error.*  Our 
death-registers  contain  innumerable  entries  of  deaths 
from  "  small-pox  after  vaccination,"  which  were  simply 
cases  of  death  from  small-pox  in  children  in  whom  vac- 
cination was  performed  during  the  incubation  of  small- 
pox: and  heaps  of  published  and  other  records  are 
quite  unusable  for  any  statistical  purposes,  because 
cases  of  this  kind  are  not  distinguished  from  the  cases 
in  which  small-pox  really  did  occur  in  persons  who  had 
properly  received  the  constitutional  infection  of  vac- 
cination.f 

*  "Pascal  a  dit  qu'on  ne  fait  jamais  mieux  le  mal  que 
quand  on  le  fait  en  surete  de  conscience.  Telle  etait  la  posi- 
tion de  ces  medecins  qui  refusaient  la  vaccine  a  ceux  qui  la 
demandaient,  de  peur  d'attirer  sur  eux  la  maladie  regnante." 
(Kapport  de  l'Acad.  Koy.  de  Med.  sur  les  Vacc.  etc.  1846, 
p.  16.) 

f  In  cases  of  small-pox  in  persons  on  whom  vaccination  ha3 
only  a  short  time  before  been  performed,  the  most  scrupulous 
attention  should  be  given  to  dates,  whether  in  recording  cases 
for  one's  own  information,  or  in  certifying  deaths.  The  date 
of  the  successful  vaccination,  and  the  date  of  the  first  or  pre- 
monitory symptoms  of  the  small-pox,  should  always  be  care- 
fully noted.  Might  I  venture  to  urge  also  on  my  professional 
brethren  a  more  careful  use  of  the  word  "vaccinated"'  in 
death-certificates?  I  have  known  deaths  from  small-pox 
medically  certified  as  "vaccinated,"  when  it  was  admitted  on 
inquiry  that  vaccination  had  only  been  attempted,  and  had 
been  without  result. 


OF   VACCINATING.  123 

The  practice,  which  I  have  known  at  times  adopted, 
of  vaccinating  a  person  after  symptoms  of  small-pox 
have  actually  manifested  themselves,  is  utterly  absurd  : 
so  far  as  the  patient  is  concerned,  the  effect,  of  course, 
is  nil ;  but  on  account  of  the  discredit  it  tends  to  bring 
upon  vaccination  with  the  public,  it  is  a  practice  which 
should  be  strongly  discountenanced. 

(b)  Selection  of  the  Lymph  to  b  2  used  in  Vaccinating. 
— This  is  a  matter  of  the  utmost  consequence.  The 
lymph  must  be  taken  only  from  perfectly  healthy  sub- 
jects, and  from  thoroughly  characteristic  vesicles.  No 
second-rate  vesicles  should  ever  be  used  to  take  lymph 
from.  Babies  are  in  general  much  better  lymph-givers 
than  elder  children  or  adults.  Children  of  dark  com- 
plexion, not  too  florid,  with  a  thick,  smooth,  clear  skin, 
are  those  which  yield  the  finest  and  most  effective 
lymph.  Prime  lymph  is  always  perfectly  limpid,  and 
has  besides  (and  no  less  essentially)  a  certain  degree 
of  viscidity.  A  thin  serous  lymph  is  always  to  be 
avoided  (see  note,  p.  91).  With  regard  to  the  period 
of  the  vesicle's  course  at  which  the  lymph  should  be 
taken  from  it,  this  may  be  done,  and  with  perfect  pro- 
priety, as  soon  as  ever  the  vesicle  will  yield  any ;  such 
lymph,  though  it  can  only  be  got  in  small  quantity,  is 
very  effective.  Usually,  however,  lymph  is  not  taken, 
nor  for  the  purposes  of  good  vaccination  is  there  any 
necessity  whatever  that  it  should  be  taken,  until  the 
vesicle  is  fully  formed,  which,  in  regular  cases,  is  the 
day  week  from  the  vaccination.  The  vesicle  then 
yields  lymph  of  the  best  quality,  and  in  sufficient 
abundance.  It  must  be  taken,  however,  according  to 
Jenner's  "golden  rule,"  before  the  appearance  of  the 
areola,  or  at  all  events  within  a  very  few  hours  of  its 


124  HANDBOOK  OF   VACCINATION. 

commencement.  No  greater  mistake  can  be  made  than 
that  of  taking  it  later,  and  when  the  areola  is  fully  com- 
plete. The  protest  which  Jenner  felt  it  necessary  to 
make  against  this  practice  in  the  earlier  days  of  vac- 
cination has  been  repeated  by  every  vaccinator  of 
authority  since  his  time.  No  doubt  the  lymph  flows 
more  freely  at  this  late  period,  and  may  be  got  in 
greater  abundance,  and  no  doubt  also  (as  is  alleged  by 
those  who  defend  this  practice)  such  lymph  very  often 
takes ;  but,  in  the  first  place,  it  does  not  take  with  any- 
thing like  the  same  certainty  as  earlier  and  more  active 
lymph,  and,  in  the  second  place,  it  is  more  apt  to  be 
followed  by  erysipelatous  and  spurious  results.  I 
repeat,  that  judicious  choice  of  lymph — the  taking  it 
only  from  suitable  subjects,  from  the  primest  vesicles, 
at  the  proper  time — is  a  cardinal  point  in  good  vaccina- 
tion. And  I  will  venture  to  say  that  just  in  propor- 
tion as  the  rules  here  laid  down — rules  sanctioned  by 
all  the  best  authorities — are  adhered  to,  so  will  success 
be  attained,  and  irregularities  in  the  course  of  the  vac- 
cinations performed  be  avoided. 

(c)  Performance  of  the  Vaccination:  (1)  Collection 
of  the  Lymph. — A  child  and  a  vesicle  fit  for  the  pur- 
pose having  been  selected,  the  vaccinator,  in  order  to 
collect  the  lymph,  proceeds  to  open  the  vesicle  by  a 
number  of  minute  punctures,  which  must  be  made  on 
its  surface,  and  not  round  the  base.  The  object  of 
many  punctures  is  to  open  the  various  cells  of  the  vesi- 
cle in  which  the  lymph  is  contained,  and  the  reason  for 
making  these  on  the  surface  and  not  round  the  base  is 
to  obtain  the  lymph  free  from  any  admixture  of  blood. 
If  by  accident  any  blood  be  drawn,  this  must  be  allowed 
to  coagulate,  and  then  be  carefully  removed  before  tak- 


OF   VACCINATING.  125 

ing  the  lymph ;  for  it  is  a  rule,  never  to  be  deviated 
from,  that  the  vaccination  must  be  with  vaccine  lymph, 
and  with  lymph  only.  When  the  cells  of  the  vesicle 
are  freely  opened,  the  lymph  soon  exudes  and  lies  on 
the  surface ;  and  thus  lying,  it  may  be  taken  on  the 
point  of  a  lancet,  or  in  any  other  way  that  is  desired, 
for  use.  On  no  account  must  there  be  any  pressure  or 
squeezing  of  the  vesicle  with  the  lancet,  or  otherwise, 
to  make  the  lymph  exude ;  and  when  lymph  ceases  to 
stand  spontaneously  on  the  surface  of  a  vesicle,  that 
vesicle  must  be  considered  no  longer  usable  for  lymph 
supply.  Very  generally,  however,  when  the  lymph 
which  has  first  exuded  has  been  taken,  and  the  surface 
of  the  vesicle  left  apparently  dry,  if  the  operator  wait 
a  minute  or  two  he  will  find  there  has  been  a  fresh 
exudation  of  good  usable  lymph ;  and  when  he  does 
not  find,  he  may  often  induce  this  in  a  way  quite  unob- 
jectionable by  wiping  very  gently  the  surface  of  the 
vesicle  with  a  soft  wet  linen  cloth,  thereby  removing 
or  dissolving  the  inspissated  lymph  which  clogs  the 
punctures.  Vesicles  of  perfect  character,  and  of  the 
same  size  and  appearance,  differ  very  much  in  their 
yield  of  lymph ;  ordinarily,  from  a  vesicle  of  such  size 
as  is  produced  by  a  single  deep  puncture,  enough  lymph 
may  be  got  for  the  direct  vaccination  of  from  four  to 
six  children,  or  for  charging  (i.e.  for  well  charging, 
dipping  once  and  again)  six  to  eight  ivory  points. 
Some  vesicles  yield  much  more,  but  the  caution  already 
given  against  a  thin,  serous,  too  readily  flowing  lymph, 
must  be  borne  well  in  mind.  When  vesicles  are  com- 
pound, their  yield  of  lymph  is  of  course  proportionably 
increased. 

(2)  Considerations  respecting  Vaccinating  from  the 
Arm,  or  with  stored  Lymph. — Lymph  should  in  every 


126  HANDBOOK  OF   VACCINATJON. 

instance  (where  practicable)  be  inserted  direct  from 
arm  to  arm.  Vaccination  with  preserved  and  con- 
veyed lymph — whatever  the  mode  of  preservation  and 
conveyance — is  in  the  long  run  far  less  successful  than 
direct  vaccination,  and  should  only  be  adopted  in  case 
of  necessity.  But  a  caution,  which  experience  has 
shown  me  to  be  much  called  for,  must  be  interposed. 
The  superior  relative  advantages  of  arm-to-arm  vaccin- 
ation are  so  generally  appreciated  by  vaccinators,  that 
practitioners  whose  vaccinations  are  few,  and  whose 
opportunities  of  lymph  selection  are  therefore  limited, 
are  often  induced  to  take  lymph  from  second-rate  vesi- 
cles, rather  than  lose  the  opportunity  of  vaccinating 
direct  from  an  arm.  This,  which  I  know  to  be  the 
source  of  much  current  inferior  vaccination,  is  a  course 
which  should  not  be  adopted.  It  is  better  to  employ 
preserved  lymph  of  first-rate  quality  (and  no  lymph 
which  is  not  first-rate  ought  ever  to  be  preserved),  with 
of  course  such  extra  care  in  the  insertion  of  it  as  the  use 
of  stored  lymph  always  requires,  than  for  the  sake  of  a 
direct  vaccination  to  take  lymph  from  an  inferior  vesicle. 
Best  of  all  is  it,  unless  circumstances  forbid,  to  put  off 
the  vaccination  till  there  is  an  opportunity  of  doing  it 
direct  from  the  arm,  from  a  thoroughly  satisfactory 
vesicle. 

(3)  Various  Methods  of  inserting  Lymph. — Various 
methods  may  be  employed  for  inserting  lymph,  the 
essential  part  of  all  of  them  being  either  to  introduce 
the  lymph  into  the  substance  of  the  cutis,  or  to  bring  it 
well  in  contact  with  its  absorbing  surface,  (a)  One  of 
the  most  familiar  methods  is  that  of  puncture.  When 
it  is  intended  to  operate  in  this  way,  the  arm  of  the 
child  to  be  vaccinated  should  be  grasped  by  the  left 


OF   VACCINATING.  127 

hand  of  the  vaccinator,  so  as  to  put  the  skin  on  the 
stretch,  and  a  very  sharp,  perfectly  clean  lancet,  well 
charged  with  the  lymph  selected,  should  be  introduced 
by  valvular  puncture  from  above  downward,  so  that 
the  lymph  may  gravitate  into  the  wound.  The  lancet 
should  not  be  held  level  with  the  skin,  but  at  an  angle 
of  45°,  or  thereabouts,  and  made  to  enter  the  cutis.  If 
the  lymph  be  thus  well  put  in,  it  is  retained  by  the 
valvular  character  of  the  puncture  and  the  elasticity  of 
the  skin;  and  any  fear  that  the  bleeding  which  ensues 
will  cause  the  vaccination  to  fail  -is  quite  chimerical.* 
Superficial  puncture,  on  the  other  hand,  unless  the 
lancet  be  thrust  far  under  the  cuticle,  so  as  to  bring  the 
lymph  into  contact  with  a  considerable  extent  of  ab- 
sorbing surface,  will  oftener  fail,  or  will  result  in  much 
smaller  vesicles.  In  vaccinating  by  puncture  not  less 
than  five  should  be  made,  and  they  should  be  at  a  dis- 
tance of  half  an  inch  from  each  other.  Five  or  more 
punctures  at  this  distance  from  each  other  can  very 
well  be  made  in  one  arm  if  the  vaccinator  prefer  to  vac- 
cinate on  one  arm  only,  or  three  or  four  may  be  made 
on  each  arm.f     Six  or  seven  vesicles,  such  as  ordinarily 

*  Among  high  authorities,  Gregory  and  Marson  hoth  insist 
strongly  on  the  advantages  of  making  the  punctures  suffi- 
ciently deep;  and  Bousquet  ridicules  the  notion  of  the  blood 
that  flows  washing  the  lymph  away,  if  this  have  only  been 
put  in  properly  in  the  way  recommended  in  the  text,  and  re- 
marks also  on  the  finer  vesicles  which  ensue  from  a  deep,  than 
from  a  superficial,  puncture.  (Rapport  de  I'Acad.  Imp.  for 
1850.)  My  own  experience,  as  the  text  shows,  entirely  coin- 
cides with  that  of  these  vaccinators. 

•j-  It  is  not  a  little  surprising  to  those  who  are  familiar  with 
the  practice  of  the  National  Vaccine  Establishment,  and  of 
other  first-class  vaccinating  stations  in  England,  where  nun- 


128  HANDBOOK  OF   VACCINATION. 

result  from  puncture,  are  not  at  all  too  many  for  complete 
protection,  and  are  just  as  well  borne  by  infants  as  one 
or  two  would  be.  In  the  manipulations  by  which  vac- 
cination is  effected  by  puncture,  it  is  a  very  good  plan 
to  make  each  puncture  a  double  one,  thus  /  /.  A  finer 
and  larger,  often  oval,  compound  vesicle  is  thereby 
raised.  For  vaccination  by  puncture  no  instrument  is 
needed  but  a  common  lancet,  very  sharp :  most  of  the 
special  instruments  which  have  been  devised  for  the 
purpose  are  not  nearly  so  good ;  none  certainly  has  any 
advantage  over  it,  and  it  is  therefore  not  necessary  to 
enter  into  any  description  of  them.  (6)  A  modification 
of  the  plan  of  vaccinating  by  puncture  is  that  of  mul- 
tiple superficial  puncture,  or  tattooing  ;  a  number  of 
minute  superficial  punctures  being  made  over  one  spot 
with  the  point  of  the  lancet,  thus  <4R8»  and  the  lymph 
then  spread  over  with  the  flat  part  N&?"  of  the  lancet. 
The  number  of  spots  over  which  this  tattooing  should 
take  place  will  depend,  of  course,  on  the  extent  of  sur- 
face operated  on  at  each  spot.  Tattooing  over  such  a 
surface  as  is  above  depicted,  should  be  repeated  on  as 

dreds  of  thousands  of  children  have  heen  vaccinated  in  this 
way  without  the  least  danger  having  been  incurred,  or  with 
the  practice  of  various  continental  kingdoms,  to  hear  this  num- 
ber of  punctures  excepted  to  as  if  it  imported  some  "  danger" 
to  a  child.  More  than  one  practitioner  has  told  me  he  would 
not  mind  trying  two  punctures,  but  he  should  be  quite  afraid 
to  make  three!  Heim  recommends  six  punctures,  three  on 
each  arm  ;  Marson  always  makes  six  ;  Bousquet  six,  even  on 
children  a  day  old ;  and  in  tbe  vaccinations  to  which  refer- 
ence was  made  in  the  former  note,  as  performed  in  France 
shortly  after  birth,  the  usual  course  of  operating  appears  to 
have  been  by  six  punctures.  Steinbrenner  makes  ten  punc- 
tures, five  on  each  arm.  I  am  informed  that  it  is  usual  in 
Prussia  to  make  sixteen  punctures. 


OF   VACCINATING.  129 

many  spots  as  one  would  operate  on  by  the  method  of 
puncture  above  described, —  that  is,  on  at  least  five 
spots,  and  preferably  on  six  or  seven.      But  if  the 
tattooing  at  each  spot  be  done  over  a  larger  surface, 
as  some  practitioners  prefer,  raising  compound  vesi- 
cles of  larger  extent,  or  sometimes  crops  of  vesicles,  at 
each  spot,  the  operation  need  of  course  be  done  over 
fewer  spots;  thus,  a  tattooing  such  as  this,      ,.f>t 
over  two  spots  on  each  arm,  or  three  spots   yr'J'J' 
on  one  arm,  would  be  sufficient,     (c)  Another     **** ' 
modification  of  puncture,  common  in  some  of  the  north- 
ern  districts  of  England,  is  that  of  first   spreading 
the  lymph  on  the  arm  of  the  child  to  be  vaccinated, 
and  then   ripping  up   the  cuticle   with  the  point   of 
the  lancet  (which  for  this  purpose  should  not  be  too 


/-/• 


/• 


sharp)  over  a  surface  equal  to  a  sixpenny 
piece  or  more,  with,  frequently,  a  second      /*  f^S  f 
plastering  of  lymph  afterward :  crops  of  f  -    /"  /* 
vesicles,  close  set  together  and  nearly  al-        /•/•/* 
ways  confluent,  are  thus  raised,  often  from         f, 
a  dozen  to  twenty  on  one  base,  each  vesicle  having  its 
distinct  depressed  head,  but  prevented,  of  course,  by  the 
pressure  of  surrounding  vesicles  from  developing  itself 
in  the  way  separate  vesicles  do.      Two  such  crops 
which  may  be  made  either  one  on  each  arm,  or  both  on 
one  arm,  may  be  regarded  as  sufficient  for  full  protec- 
tion,    (d)    Many  practitioners  prefer  vaccinating  by 
scarification,  to  the  plan  of  vaccinating  by  puncture. 
Scratches,    single   or   double,   like       .     ..  these,  each 
about  half  an  inch  or  more  long,  but     /    /  at  distances 
which  should  be  from  half  to  three-  /    /    quarters  of 
an  inch  apart  from  each  other  on  the'     "      arm,  are 
made  with  the  point  of  a  lancet,  or  with  a  thick  needle, 
12 


130  HANDBOOK   OF   VACCINATION. 

and  the  lymph  is  then  rubbed  on.*  In  the  course  of 
-p.  /7\  each  scratch  two  or  three  separate  vesicles 
jL/  /  i W*^  arise>  or  more  frequently  one  oblong 
[  I  compound  vesicle  will  be  produced.  Two 
P^  I  /  scratches  of  this  kind  should  be  made  on 
VJ/  each  arm,  or  four  on  one  arm.  (e)  An  ex- 
cellent modification  of  scarification,  very  generally 
adopted,  consists  in  abrading  the  cuticle  by  a 
number  of  fine  parallel  scratches,  thus:  /k, 
or  by  further  cross-scratches,  thus:     A  //W 

Abrasion  should  only  be  carried  Jmk 
so  far  as  to  make  it  certain,  by  the  /W>  appear- 
ance  of  blood  oozing,  that  the  cutis  is  reached ;  it 
is  better,  therefore,  not  to  use  for  this  purpose  too 
sharp  a  lancet:  the  oozing  that  occurs,  or  the 
bleeding,  if  it  should  amount  to  that,  is  then  rapid- 
ly wiped  away  with  the  finger,  and  the  lymph  is 
plastered  on.  Just  as  in  tattooing,  it  depends  on 
the  extent  of  surface  abraded  on  each  spot,  how 
many  abrasions  it  is  desirable  to  make.  When 
the  abrasion  is  made  over  such  surface  as 
this,  /%  o^,  five  or  six  should  be  employed; 
but  <///  w  when,  as  is  the  custom  of  many 
practitioners,  the  abrasion  is  made  over  a  consid- 
erably larger  surface,  as  above  depicted,  two  on 
each  arm,  or  three  on  one  arm,  about  three-quar- 
■WW  ters  of  an  inch  or  an  inch  from  each  other,  will  be 

*  In  Denmark  an  instrument  (invented  by  Professor  Dryer, 
of  Copenhagen),  which  in  appearance  resembles  the  iron  pen, 
with  two  legs  and  screw  for  regulating  their  distance,  com- 
monly contained  in  cases  of  philosophical  instruments,  but 
which  has  the  extremities  of  the  legs  broad  and  sharp  instead 


OF   VACCINATING.  131 

sufficient.  Although  for  the  performance  of  vaccina- 
tion by  scarification  no  instrument  can  be  better  than 
a  common  lancet,  many  practitioners  prefer  a  very  good 
little  instrument  invented  by  Dr.  Gr.  Weir, — a  sort  of 
rake,  consisting  of  four  needle-points  inserted  in  a 
handle  of  ivory.  (See  preceding  page.)  The  skin 
being  held  very  tense,  this  rake  is  drawn  tightly  across 
in  one  direction,  and  then,  if  the  operator  pleases, 
crossed  in  another ;  a  little  spatula  at  the  other  end  of 
the  instrument  being  employed  for  collecting  the  lymph 
and  plastering  it  on  the  abraded  surface. 

For  the  performance  of  the  nice  and  delicate  opera- 
tion of  vaccination,  the  most  scrupulous  care  should 
be  taken  to  keep  the  instruments  employed  clean  and 
in  good  order.  Lancets  that  are  used  for  any  other 
purpose  should  never  be  employed  for  vaccinating ; 
and  vaccinating  lancets  should  not  only  be  cleaned 
before  being  put  away,  but  when  several  children  are 
to  be  vaccinated  at  a  sitting,  a  cup  of  water  and  a 
napkin  should  always  be  on  the  table,  and  the  lancet 
dipped  and  wiped  after  each  operation. 

(4)  Particular  steps  necessary  when  the  Lymph 
used  is  dry-stored. — In  the  above  descriptions  it  has 
been  assumed  that  the  vaccinator  was  operating  imme- 
diately from  child  to  child;  and  the  same  directions 
are  sufficient  when  he  uses  lymph  that  has  been  con- 
veyed or  preserved  (Chap  VIII.)  in  the  liquid  form, 
as  in  the  vaccine  bottle,  in  capillary  tube,  sor  in  any 
other  way.     But  when  he  has  to  use  lymph  that  has 

of  being  pointed,  is  extensively  employed  for  this  form  of  lon- 
gitudinal scarification.  It  answers  its  purpose  very  well,  but 
no  better  than  a  common  lancet  properly  employed. 


132  HANDBOOK  OF   VACCINATION. 

been  preserved  by  drying,  as  on  points  or  glasses,  it 
will  be  necessary  this  should  be  revived,  or  brought 
back  to  the  liquid  state,  in  order  that  it  may  be  taken 
up  by  the  system.  This  may  be  done  by  the  use  of 
a  very  minute  quantity  of  cold  water ;  if  the  lymph 
to  be  revived  has  been  preserved  on  glasses,  a  very 
small  drop  of  water  should  be  taken  on  the  point  of 
the  lancet  and  well  rubbed  in  with  it,  and  the  lymph 
left  for  some  minutes  to  soften  ;  if  it  has  been  kept  on 
points,  these  should  be  very  lightly  and  for  a  moment 
dipped  in  the  water,  the  superfluous  water  shaken  off, 
and  the  moistened  point  left  for  a  few  minutes  on  the 
edge  of  a  book  for  the  lymph  to  soften.  Then,  if  the 
vaccination  is  to  be  done  by  puncture,  the  revived 
lymph  should  be  taken  on  the  lancet-point,  and  inserted 
as  in  a  vaccination  direct  from  arm  to  arm  ;  or,  better 
still,  supposing  the  lymph  has  been  preserved  on  points, 
punctures  may  be  made  with  a  clean  uncharged  lancet, 
and  the  ivory  points  themselves  then  inserted  into 
these  punctures,  and  kept  in  position  by  the  thumb 
for  a  short  time — care  being  taken  to  press  the  thumb 
well  down  as  the  points  are  being  withdrawn,  so  that 
the  lymph  may  be  thoroughly  wiped  off  them  and  left 
in  the  wound.  If  the  vaccination  is  to  be  done  by 
scarification  or  abrasion,  the  revived  lymph  may  either 
be  taken  on  the  lancet  and  applied  as  in  an  ordinary 
wet-lymph  vaccination,  or  the  flat  of  the  glass  or  the 
flat  of  the  point  may  be  itself  rubbed  over  the  scarified 
or  abraded  surface.  When  the  lymph  on  the  point  or 
glass  has  not,  by  keeping  or  otherwise,  become  very 
dry,  the  oozing  of  the  abraded  surface  will  generally 
afford  all  the  moisture  that  is  needed  for  its  revival. 
When  the  scab  is  employed  for  vaccinating  it  must 


OF   VACCINATING.  133 

be  well  moistened,  and  worked  up  with  a  little  cold 
water  on  a  slab  or  the  back  of  a  plate,  by  means  of 
a  clean  knife,  and  abundance  of  the  ropy  solution  in- 
serted. 

(5)  Is  any  one  mode  of  insertion  better  than 
another? — An  important  question  arises,  whether  any 
one  of  the  different  modes  of  inserting  lymph  above 
described,  or  of  numerous  modifications  of  them  that 
are  met  with  in  practice,  can  be  more  relied  on  than 
another  for  producing  success.  The  only  difference 
that  I  am  aware  of,  to  a  careful  man  who  thoroughly 
understands  his  work,  is  this, — that  he  will  succeed 
best  in  the  way  to  which  he  is  most  accustomed.  So 
much  depends  on  habit,  and,  if  I  may  so  say,  on  trick 
of  hand,  that  a  practitioner  who  has  learned  properly 
how  to  vaccinate,  say  by  ordinary  puncture,  and  can 
rely  on  securing  thus  the  results  he  aims  at,  is  more 
likely  to  be  disappointed  than  gratified  by  attempting 
to  change  his  plan  for  any  other,  and  vice  versa.  There 
is  not,  in  fact,  one  of  these  plans  by  which  I  have  not 
seen  the  best  results  of  vaccination  produced  with  sin- 
gular uniformity  and  constancy  by  various  practitioners, 
and  if  a  score  of  the  best  vaccinators  in  England  were 
picked  out,  there  can  be  no  doubt  that  each  form  of 
working  which  I  have  described  would  have  its  repre- 
sentative. Nothing  certainly  can  be  finer,  or  more 
completely  models  of  what  vaccination  should  be,  than 
such  results  as  Marson  and  some  other  vaccinators 
produce  by  the  process  I  first  described, — that  of  sim- 
ple puncture.  Still,  whether  it  be  that  this  plan  has 
been  often  imperfectly  taught  (for  few  teach  it  and 
practice  it  as  Marson  teaches  and  practices  it),  or 
whether  it  be  in  itself  more  difficult  than  the  other 
12* 


134  HANDBOOK  OF   VACCINATION. 

ways  described,  large  opportunities  of  observing  the 
general  practice  of  vaccination  throughout  England 
have  left  no  doubt  on  my  mind,  that  in  most  hands  it 
has  been  much  less  successful  than  the  others.     This 
is  especially  the  case  when,  as  in  country  practice, 
conveyed  lymph  or  dry  lymph  has  frequently  to  be 
employed.     I  have,  in  fact,  found  comparatively  few 
persons  making  dry  lymph  take  well  by  simple  punc- 
ture ;  and  for  vaccinations  under  these  circumstances, 
at  all  events,  some  of  the  forms  of  abrasion  or  scarifi- 
cation are  in  most  hands  by  far  the  most  successful.* 
Looking  broadly  at  the  results  I  have  met  with  in  the 
practice  of  large  numbers  of  vaccinators,  and  with  no 
personal  prejudice  in  its  favor  (for  it  is  not  the  mode  in 
which  I  have  ever  myself  been  in  the  habit  of  vaccina- 
ting), it  appears  to  me  that  no  method  is  more  highly  to 
be  recommended  than  that  of  parallel  scratches,  crossed 
or  not  crossed,       dfc,     and  this  whether  regard 
be  had  to  the    Mm   infrequency    of    failure, 
or  to  the  size,     ^W     depth,  and  foveation  of 
the  resulting  cicatrices.     And  this  conclusion  in  favor 
of  abrasion  or  scarification  has,  I  believe,  pressed  itself 
on  the  minds  of  all  those  who  have  taken  part  with 
me  in  the  inspection  of  public  vaccination  in  England. 
51.  Watching  the  Course  of  Vaccination.    Inspec- 
tion of  Results. — When  the  performance  of  vaccination 
is  completed,  a  particular  charge  should  be  given  to 
the  parent  to  keep  the  arms  from  rubbing  or  other  me- 
chanical irritation,  and  means  should  be  taken  for  seeing 

*  Ceely  is  of  the  same  opinion.  "  With  dry  lymph  on 
points,"  says  he,  "  there  is  no  mode  equal  to  that  for  certainty, 
and  I  have  tried  many."  (See  Appendix  to  Badcock's  Detail 
of  Experiments,  etc.,  p.  7.) 


OF   VACCINATING.  135 

the  child  again  on  the  same  day  of  the  following  week, 
that  the  success  of  the  operation  may  be  ascertained. 
Such  inspection  is  important  to  the  practitioner,  in 
order  that,  in  suitable  cases,  he  may  be  able  to  obtain 
lymph  from  the  vesicles  that  have  been  produced, 
whether  for  immediate  use  or  for  storage.  It  is  indis- 
pensable to  the  parent,  who,  without  it,  can  never  be 
sure  that  the  object  of  vaccination  is  gained,  that  the 
child  is  really  protected  against  small-pox.  This  is  not 
a  point  which  an  uninitiated  person  can  determine  for 
himself;  he  can  only  know  that  an  effect  has  been  pro- 
duced, not  whether  the  specific  effect  which  alone  makes 
the  child  safe  has  followed.  On  various  occasions  I 
have  known  parents  in  perfect  good  faith,  and  without 
the  slightest  intention  of  deceiving,  affirm  that  a  vac- 
cination has  taken  beautifully,  when  inspection  has 
shown  that  the  results  were  spurious.  The  law,  there- 
fore, requires  that  children  should  not  only  be  vaccin- 
ated, but  that  a  vaccination  should  always  be  duly  in- 
spected ;  nor,  without  actual  inspection,  can  a  medical 
practitioner  properly  give  a  certificate  of  successful 
vaccination.  When,  on  this  eighth-day  inspection, 
vesicles  of  a  perfectly  characteristic  kind  are  found  to 
have  risen,  it  is  not  very  likely  that  anything  in  the 
subsequent  course  of  the  vaccination  will  interfere  with 
its  protective  value,  and  the  practitioner  will  seldom 
find  that  he  has  made  a  mistake,  who  (besides  giving 
the  parent  the  certificate  of  success  to  which  he  is  then 
legally  entitled)  should  venture  also  to  pronounce  the 
child  safe;  at  the  same  time  this  assurance  might  be 
given  with  more  absolute  certainty  were  the  case  seen 
through  the  stage  of  areola,  and  I  cannot  but  think  it 
is  to  be  regretted  that  the  old  custom  of  inspecting  the 


136  HANDBOOK  OF   VACCINATION. 

vaccination  on  the  eleventh  or  twelfth  day,  as  well  as 
on  the  eighth,  should  have  fallen  into  disuse.  Without, 
however,  insisting  on  a  second  inspection  in  a  perfectly 
regular  case,  my  experience  compels  me  to  urge  strongly 
the  necessity  of  such  further  inspection  in  all  cases 
where  the  appearances  on  the  day-week  are  retarded, 
or  in  any  degree  dubious.  Many  times  have  I  known 
assurance  given  that  the  case  was  "all  right,"  when, 
from  retardation,  the  vesicles  were  so  little  advanced 
in  their  course  that  it  was  impossible  for  the  practi- 
tioner then  properly  to  determine  it;  and  I  have  also, 
in  non-retarded  but  dubious  cases,  seen  results  on  the 
day-week  so  far  resembling  the  normal  effects  of  vaccina- 
tion that  to  an  inexperienced  person  they  might  readily 
have  seemed  such,  and  that  an  experienced  person,  if 
compelled  then  to  decide,  would  have  been  inclined  to 
pronounce  them  regular,  and  which  yet,  on  further 
watching,  turned  out  irregular  and  spurious.  The 
only  safe  rule,  therefore,  with  regard  to  doubtful  or 
retarded  cases,  is  to  inspect  them  again.  Whenever  a 
case,  whether  on  the  day-week  or  on  subsequent  in- 
spection, is  found  to  be  spurious,  the  parents  should 
be  most  carefully  warned  not  to  rely  on  that  vaccina- 
tion as  protective  against  small-pox,  but  to  have  the 
operation  repeated  either  at  once,  if  it  be  quite  certain 
that  the  cause  of  irregularity  is  not  in  the  child's  own 
health  or  condition,  or  else  after  an  interval  of  a  few 
weeks  or  months. 

52.  Performance  of  Vaccination  from  the  Natural 
or  Casual  Disease  in  the  Cow. — Opportunities  of  seeing 
the  natural  disease  in  the  cow  are  not  common,  but  for 
the  sake  of  those  to  whom  they  may  chance  to  occur, 
and  who  may  conceive  that  some  advantage  may  attend 


OF   VACCINATING.  137 

the  raising  a  fresh  stock  of  lymph  from  such  cases,  it 
is  desirable  to  offer  a  few  hints,  taken  chiefly  from 
Ceely's  admirable  and  oft-quoted  memoir,  both  as  to 
the  collection  of  the  lymph  and  as  to  the  insertion  of 
it.  A  practitioner  in  search  of  such  lymph  will  often 
have  to  take  a  great  deal  of  trouble  and  be  doomed  to 
much  disappointment.  He  will  frequently  find  himself 
deceived  by  false  reports,  and,  when  he  arrives,  see 
some  spurious  disease  instead  of  the  genuine  cow-pock. 
Even  if  the  pock  be  genuine,  the  period  for  taking 
lymph  will  most  probably  have  gone  by,  and  it  is,  in 
fact,  only  when  a  number  of  animals  are  affected  in 
succession  in  a  dairy  that  there  is  much  chance  of  find- 
ing any  vesicles  fit  to  yield  lymph.  Careful  search, 
especially  on  the  lower  and  naked  parts  of  the  udder 
and  the  adjoining  bases  of  the  teats,  should,  however, 
be  made,  with  the  view  of  finding,  if  possible,  some 
entire  unacuminated  vesicles,  or  vesicles  with  central 
crusts.  The  former,  if  found,  should  be  punctured  with 
a  sharp  lancet  as  near  the  center  of  the  vesicle  as  pos- 
sible, ana"  the  epidermis  gently  raised  to  a  moderate 
extent  round  the  discolored  or  most  depressed  part. 
The  greatest  delicacy  in  manipulation  throughout  the 
examination  and  subsequent  puncture  is  necessary,  for 
the  quantity  of  lymph  is  exceedingly  small,  and  exu- 
dation of  blood  will  obscure  it,  or  sensitiveness  of  the 
animal  under  a  rough  manipulation  prevent  the  opera- 
tion altogether.  With  due  care,  slight  gentle  pressure 
either  with  the  blade  of  the  instrument,  or  between  the 
thumb  and  finger,  will  enable  the  operator  to  charge  a 
few  points.  "  Patience  and  a  treble  charging  of  the 
points  are  always,"  says  Ceely,  "  to  be  recommended." 
Puncture  at  the  elevated  and  indurated  margin  of  the 


138  HANDBOOK  OF   VACCINATION. 

vesicle  will  be  useless,  only  yielding  blood.  Vesicles 
with  central  crusts  will  be  found  perhaps  more  con- 
venient than  the  entire  unacuminated  vesicles,  and  will 
yield  nearly  as  much  lymph,  if  the  crust  be  small  and 
the  margin  of  the  vesicle  tender,  hot,  and  tumid.  The 
crust  may  be  removed  or  pressed  on  one  side,  the  epi- 
dermis then  carefully  raised,  and  a  limpid  fluid  in  small 
quantities  thus  obtained.*  Small  superficial  vesicles 
will  often  yield  more  lymph  than  contiguous  larger 
vesicles  more  deeply  seated. 

When  we  are  deprived  of  opportunities  of  getting 
lymph  in  either  of  these  ways,  we  may  often  succeed 
by  reviving  (1)  amorphous  masses  of  concrete  lymph 
which  have  exuded  from  broken  vesicles ;  (2)  the  cen- 
tral rough  and  irregular  crusts,  the  more  transparent 
and  nearer  a  dark  brown  the  better ;  (3)  desiccated 
vesicles,  or  formed  crusts,  if  of  primary  formation,  the 
secondary  and  tertiary  crusts  being  of  scarcely  any 
value. 

It  is  before  acumination  that  we  must  always  look 
for  lymph  from  the  cow :  after  acumination,  lymph  is 
comparatively  of  little  value.    The  vesicle  immediately 

*  In  like  way,  when  we  desire  to  vaccinate  from  the  casual 
vesicle  of  a  milker,  and  the  case,  as  may  often  he,  has  not 
come  under  our  observation  till  the  vesicle  is  well  advanced, 
the  areola  perhaps  declining,  as  at  the  tenth  day,  effective 
lymph  may  still  be  got  from  the  center  of  the  vesicle.  Dis- 
place the  fragment  of  concrete  lymph  which  occupies  this 
center;  wipe  away  with  repeated  dossils  of  lint  the  turbid 
serous  fluid  which  issues.  The  lancet  will  then  be  able  to  take 
up,  though  probably  not  without  some  intermixture  with  the 
turbid  opaque  fluid,  a  tenacious  limpid  lymph  from  the  deep 
center  of  the  vesicle.  (Trans.  Prov.  Med.  and  Surg.  Assoc, 
vol.  x.  p.  245.) 


OF   VACCINATING.  139 

before  acumination  will  yield  it'in  as  active  a  state  as 
earlier ;  while  at  an  earlier  period,  as  from  the  fifth  to 
the  ninth  day,  it  is  scarcely  possible  to  obtain  it  in  any 
quantity.  In  the  early  stages  of  some  vesicles,  espe- 
cially those  which  are  superficial  or  have  been  irritated, 
lymph  may  be  turbid  and  even  bloody  without  impair- 
ment of  its  efficacy.  Even  turbid  lymph  from  an  un- 
acuminated  vesicle  will  answer  when  limpid  lymph 
from  an  acuminated  one  will  fail.  Lymph  will  generally 
be  found  more  abundant  on  the  cow  than  on  the  heifer, 
more  abundant  and  less  viscid  on  the  teats  than  on  the 
udder. 

To  establish  and  maintain  a  stock  of  lymph  from  the 
cow,  we  must  be  careful  to  have  at  hand  a  sufficient 
number  of  subjects  to  receive  it,  whether  direct  or 
through  its  earliest  removes.  Young  infants  with  a 
thick,  smooth,  clear  skin  and  a  dark  complexion,  but 
not  too  florid,  are  the  best.  Strumous,  thin-skinned 
children  should  be  avoided.  And  this  selection  must 
be  adhered  to  with  great  care  until  (which,  however,  is 
generally  the  case  in  a  very  few  removes)  the  local  in- 
tensity of  the  symptoms  is  materially  diminished. 
With  this  very  active  lymph  three  or  four  punctures 
will  generally  be  amply  sufficient,  and  unless  we  are 
sure  of  our  subjects  it  will  be  safer  to  use  a  less  num- 
ber :  in  all  cases  it  is  a  matter  of  the  greatest  moment 
to  avoid  rupture  and  disturbance  of  the  vesicle.  If  we 
desire  for  any  reason  to  vaccinate  with  this  acrid  lymph 
any  subjects  whom  we  deem  unfavorable,  we  should 
prepare  them  beforehand,  as  the  old  inoculators  did  the 
subjects  of  variolous  inoculation.* 

*  Trans.  Prov.  Med.  and  Surg.  Assoc,  vol.  viii.  pp.  338- 
342,  and  349. 


140  HANDBOOK  OF   VACCINATION. 


CHAPTER    VII. 

OP  ARRANGEMENTS  FOR  THE  PERFORMANCE  OF  VACCINA- 
TION  AND   THE    MANTENANCE   C?   LYMPH-SUPPLY. 

53.  Great  relative  Advantages  of  Arm-to-arm  Vac- 
cination.— Vaccination  performed  direct  from  child  to 
child  with  well-selected  lymph,  in  skilled  hands,  very 
rarely  fails.  This  is  much  more  than  can  be  said  of 
any  other  mode  of  proceeding.  Lymph  conveyed  liquid 
from  patient  to  patient,  however  promptly,  does  not 
infect  with  nearly  the  same  certainty  as  the  lymph 
transferred  immediately  from  arm  to  arm;  and  stored 
or  preserved  lymph,  whatever  the  mode  of  storage  or 
preservation,  is  greatly  more  unsuccessful.  And  if  this 
be  the  case  with  the  best  operators,  the  difference  in 
less  practiced  hands  is  still  more  remarkable.  "De 
quelque  maniere  qu'on  s'y  prenne,"  says  Bousquet,  "ja- 
mais le  vaccin  conserve  ne  vaut  le  vaccin  de  bras  a 
bras."*  The  superiority,  indeed,  of  arm-to-arm  vac- 
cination is  not  a  point  which  admits  of  dispute,  and, 
by  every  practitioner  who  duly  reflects  on  the  im- 
portance of  making  vaccination  thoroughly  success- 
ful, the  performance  of  it  in  this  way  is  regarded  as  a 
matter  of  the  utmost  consequence. 

54.  Method  and  suitable  Arrangements  are  requi- 
site for  thus  performing  Vaccination. — :But  for  vac- 

*  Kapport  de  l'Academie  sur  les  Vaccinations  pratiquees  en 
France  pendant  l'Annee  1844.   • 


ARRANGEMENTS  FOR    VACCINATION.         141 

cinating  from  arm  to  arm,  and  especially  for  carrying 
on  a  series  of  such  vaccinations,  method  and  suitable 
arrangements  are  indispensable.  "  Our  arrangements," 
says  Jenner,  writing  to  a  gentleman  whose  children  he 
had  undertaken  to  vaccinate,  "must  be  carefully  made, 
as  the  children  must  be  met  here  by  proper  subjects  for 
transferring  the  lymph ;  for  on  the  accuracy  of  this  part 
of  the  process  much  depends."  But  how  can  we  make 
sure  of  having  proper  subjects  for  supplying  lymph  for 
a  day's  vaccinations,  unless  we  have  several  children 
under  vaccination  at  the  same  time?  Every  expe- 
rienced vaccinator  knows  that  a  child  who  has  been 
successfully  vaccinated  so  as  to  be  well  protected 
against  small-pox  may  yet  not  be  a  good,  and  often 
will  not  be  an  eligible,  child  for  transmitting  lymph. 
Let  half  a  dozen  successful  cases  of  vaccination  present 
themselves  for  inspection  on  the  same  day,  and  you 
may  not  have  more  than  two  or  three,  if  so  many, 
really  choice  arms  from  which  to  carry  on  the  day's 
vaccinations;  and  a  vaccinator  who  is  dependent  on 
only  one,  two,  or  three  vaccinations  of  the  previous 
week,  is  liable  to  be  stopped  in  his  proceedings,  not 
merely  by  the  case  or  cases  having  failed,  but  by  the 
vesicles  being  such  as  experience  dictates  he  had  better 
not  employ  for  continuing  his  lymph.  If,  rather  than 
be  stopped,  he  succumbs  to  the  temptation  of  vaccina- 
ting from  such  cases,  more  especially  if  (as  such  a  vac- 
cinator is  sure  to  do)  he  succumbs  again  and  again,  he 
will  soon  find  his  stock  of  lymph  deteriorate. 

55.  Selection  of  Lymph  is  necessary  to  prevent  its 

degenerating. — Whatever  opinion  may  be  entertained 

as  to  lymph  losing  any  of  its  original  power,  necessarily 

and  inevitably,  by  the  m^rc  fact  of  its  transmission 

13 


142  HANDBOOK  OF   VACCINATION. 

through  a  succession  of  human  subjects  (a  matter  which 
will  be  discussed  hereafter),  no  one  can  doubt  that 
such  loss  of  activity  may  take  place  unless  due  care  be 
taken  in  the  selection  of  the  subjects  through  which 
the  lymph  is  continued:  and  the  best  vaccinators, 
whether  at  home  or  abroad,  lay  great  stress  on  this 
point.  Bousquet  strongly  insists  upon  it :  "S'il  y  a  un 
moyen  d'empecher  ou  du  moins  de  ralentir  la  degene- 
rescence  du  vaccin,  c'est  de  le  prendre  toujours  sur  les 
plus  beaux  enfants,  et  dans  les  plus  belles  pustules."* 
Steinbrenner  severely  condemns  the  habit  of  taking 
lymph  almost  indiscriminately  from  any  vesicles  which 
are  not  abnormal,  instead  of  choosing  only  the  most 
perfect  and  the  most  characteristic — unlike  the  wiser 
husbandman,  who*,  he  says,  picks  out  the  finest  grain 
for  his  seed-corn,  f  The  case  is  admirably  stated,  and 
the  views  of  our  own  highest  authorities  in  practical 
vaccination  are  embodied,  in  the  following  extract  from 
Simon's  preface  to  the  "  Papers  relating  to  the  History 
and  Practice  of  Vaccination :"  "  Whether  slow  pro- 
gressive degeneration  of  the  vaccine  contagion  in  its 
successive  human  transmissions  be  or  be  not  proved, 
whether  its  renewal  at  stated  intervals  from  the  cow 
be  or  be  not  an  unconditional  necessity,  the  practical 
conclusion  evidently  is,  that  its  operation  must  in  every 
case  be  intelligently  watched ;  that  no  line  of  transmis- 
sion is  to  be  continued  through  a  subject  in  whom  im- 
perfect infection  is  produced ;  that  at  any  such  point 
the  vaccinator  must  stop;  and  that  from  all  such 
points,  as  they  are  arrived  at,  reapplication  must  be 

*  Nouveau  Traite  de  la  Vaccine,  p.  228. 
f  Traite  sur  la  Vaccuie,  p.  570. 


ARRANGEMENTS  FOR    VACCINATION.         143 

made  to  the  parent  stock — not  necessarily  at  its  source, 
but  at  least  at  some  stage  of  descent  in  which  its  in- 
fective powers  are  unimpaired.  Upon  each  individual 
vaccinator  must  rest  the  responsibility  of  providing  in 
his  own  practice  against  those  obvious  chances  of  de- 
terioration of  supply.  It  becomes  difficult  or  impossible 
to  fulfill  this  obligation,  except  when  the  vaccinator 
carries  on  simultaneously  a  certain  number  of  vaccina- 
tions; so  that  he  may  be  able  at  any  time  to  choose 
between  several  arms  as  sources  for  continuing  his  con- 
tagion, and  may  never  be  tempted  to  take  lymph  other- 
wise than  from  the  typical  Jennerian  vesicle  of  a  thor- 
oughly healthy  subject.  It  is  on  these  grounds  that 
persons  who  have  given  most  attention  to  the  scientific 
culture  of  vaccination  (foremost  among  whom  I  am 
permitted  to  name  Mr.  Ceely  and  Mr.  Marson)  look 
with  some  alarm  on  our  present  minute  subdivision  of 
the  duty  of  public  vaccination,  as  tending  to  reduce 
many  public  vaccinators  to  an  objectionable  alternative ; 
either  that  they  must  have  frequent  recourse  to  extrin- 
sic assistance,  or  must  incur  the  chance  of  the  contagion 
degenerating  by  its  transmission  through  unselected 
subjects."* 

56.  Continuous  supplies  of  fresh  Lymph  depend  on 
the  arrangements  for  Public  Vaccination  in  Large 
Towns. — Although  a  full  consideration  of  the  arrange- 
ments for  public  vaccination  in  England  involves  de- 
tails which  must  be  reserved  for  a  subsequent  chapter, 
it  is  impossible  to  treat  properly  of  arm-to-arm  vaccin- 
ation, and  of  lymph-supply,  without  an  examination 
of  the  principles  on  which  a  public  system  of  vaccina- 

*  Preface  to  Papers  relating,  etc.,  p.  xxxvii.,  note 


144  HANDBOOK  OF   VACCINATION. 

tion  should  be  based.  For,  firstly,  under  the  distribu- 
tion of  vaccination  which  now  exists,  a  very  large 
majority — probably  at  the  least  two-thirds* — of  the 
children  born  are  vaccinated  by  the  public  vaccina- 
tors, and  it  depends  therefore  directly  on  the  public 
arrangements  how  far  this  large  majority  shall  have 
the  advantages  of  well-performed  arm-to-arm  vaccina- 
tion ;  and,  secondly,  inasmuch  as  circumstances  render 
it  impossible  for  any  but  the  public  vaccinators  of  large 
towns  to  maintain  continuously  stocks  of  fresh  lymph, 
and  as  there  is  a  constant  demand  for  such  lymph  for 

*  More  probably  even  tbree-fourtbs.  It  is  impossible  to 
state  exactly  what  proportion  of  each  year's  births  are  vac- 
cinated by  the  public  vaccinators  in  the  kingdom,  because,  in 
the  annual  returns  of  the  public  vaccinations  performed,  cases 
of  revaccination  are  included  without  being  distinguished 
from  primary  cases.  The  returns,  however,  give  separately 
the  vaccinations  performed  under  one  year  of  age,  which  of 
course  are  all  primary ;  and  these  alone  have  since  1854  aver- 
aged annually  more  than  half  the  registered  births.  Now,  as 
in  the  remaining,  or  minor  half,  are  included  (1)  all  that  very 
large  number  of  children  who,  remaining  unvaccinated  till 
they  are  more  than  a  year  old,  are  then  vaccinated  by  the 
public  vaccinators,  and  constitute  the  bulk  of  the  cases  an- 
nually returned  as  publicly  vaccinated  over  one  year  of  age, 

(2)  all  children  who  die  before  vaccination  has  been  done,  and 

(3)  all  living  whose  vaccination  remains  unperformed,  the 
remnant  vaccinated  by  private  practitioners  cannot,  I  think, 
exceed,  and  can  scarcely  amount  to,  one-fourth  of  the  children 
born.  It  must  further  be  borne  in  mind  that  this  small  pro- 
portion of  cases  is  distributed  among  several  times  as  many 
operators  as  are  employed  in  vaccinating  the  other  and  larger 
portion,  to  understand  the  difficulties  of  private  practitioners 
with  regard  to  maintaining  their  lymph-supply.  The  distri- 
bution of  vaccinations  into  private  and  public  varies  consider- 
ably, it  need  scarcely  be  said,  in  different  places  and  districts. 


ARRANGEMENTS  FOR    VACCINATION.        145 

the  use  of  other  practitioners  not  so  fortunately  placed, 
the  public  arrangements  adopted  in  these  towns  must, 
obviously,  indirectly  influence,  more  or  less,  the  whole 
vaccination  of  the  kingdom. 

A  very  little  consideration  of  the  subject  is  sufficient 
to  show  that  the  conditions  already  stated — viz.,  that 
for  every  arm-to-arm  vaccination  there  should  be  a 
choice  of  children  for  transferring  the  lymph,  and  that 
properly  to  carry  on  a  series  of  arm-to-arm  vaccinations 
there  must  be  several  cases  assembled  on  each  vaccin- 
ating day — are  conditions  which  only  some  out  of  the 
many  thousand  medical  practitioners  who  practice 
vaccination  in  England  can  continuously  fulfill.  For 
it  has  been  found  by  experience  that  an  average  of  ten 
vaccinations  at  a  time  is  as  little  as  can  be  relied  on 
for  the  purpose  ;  and  to  supply  this  number  of  subjects 
continuously  once  a  week,  a  vaccinator  would  need  to 
have  more  than  five  hundred  cases  a  year.*  Now 
such  an  amount  of  cases  as  this  is  not  attainable  in 

*  Of  course  with  an  average  attendance  of  ten  children  a 
week,  there  are  many  weeks  when  fifteen  or  twenty  are 
brought,  and  others  when  only  four  or  five  attend.  In  sum- 
mer the  attendance  is  always  better  than  in  winter,  and  par- 
ticular causes,  as  bad  weather,  etc.,  often  interfere  with  the 
stational  attendance  on  particular  days.  But,  the  law  requir- 
ing vaccination  to  be  performed  within  a  fixed  period  from 
birth,  it  is  found  practically  that  there  is  so  far  steadiness  of 
attendance  that,  with  the  average  stated,  some  children  are 
always  brought,  and  that  with  a  very  little  management  a 
vaccinator  may  make  sure  of  having  on  any  day  at  least  three 
or  four.  But  an  average  of  ten  is  quite  the  minimum  that 
should  be  allowed,  and  a  larger  average  gives  greater  facili- 
ties of  working,  and  greater  opportunities  of  choice.  This 
subject  is  farther  considered  in  $  57. 
1,'}* 


146  HANDBOOK  OF   VACCINATION. 

any  rural  district,  nor,  even  if  the  amount  were  attain- 
able, would  considerations  of  distance  admit  of  the 
children  in  such  districts  being  all  brought  together 
to  one  place.  It  is  not  attainable  in  small  towns,  nor 
in  any  town  where  the  births  are  less  than  seven  or 
eight  hundred  a  year,  and  frequently  is  not  attainable 
even  where  the  births  exceed  this  number,  on  account 
of  the  vaccination  of  these  children  being  distributed 
among  various  practitioners.  It  is  an  amount  which, 
even  in  our  largest  towns,  no  private  practitioner,  or 
scarcely  any  private  practitioner,  can  command.*  Con- 
stant supplies  of  fresh  lymph  can  only,  I  repeat,  be 
kept  up  by  the  public  vaccinators  of  large  towns ;  nor 
can  they  be  maintained  even  by  them,  unless  (1)  the 
authorities  have  taken  care  to  supply  the  respective 
vaccinators  with  the  requisite  number  of  cases,  and  (2) 
the  local  arrangements  have  provided  for  these  cases 
being  assembled  in  regular  weekly  succession. f 

*  In  1865  there  were  no  fewer  than  14,185,  and  in  1866  no 
fewer  than  13,718  separate  applications  for  lymph  made  to  the 
Central  Office  of  the  National  Vaccine  Establishment  alone, 
by  private  practitioners  practicing  in  England  and  "Wales  ; 
and  this  by  no  means  represents  all  the  assistance  afforded  by 
the  Establishment  to  this  portion  of  the  medical  profession, 
numerous  applications  being  made  and  satisfied  on  the  spot  at 
its  various  metropolitan  and  extra-metropolitan  stations.  And, 
in  each  of  these  years,  about  1500  applications  were  made  to 
the  establishment  from  public  vaccinators.  Besides  this,  a 
demand  for  lymph,  the  extent  of  which  there  are  no  means  of 
estimating,  is  constantly  being  made  throughout  the  kingdom 
to  district  vaccinators  unconnected  with  the  Establishment. 

f  Conditions  which  require  attention  to  the  following  gene- 
ral rules,  which  have  for  some  time  past  been  recommended 
to  local  authorities  for  their  guidance  in  this  matter : 


ARRANGEMENTS  FOR    VACCINATION.        14? 

Lymph-supply,  then,  is  a  matter  primarily  of  public, 
and  only  secondarily  of  individual  professional  arrange- 
ment. And  it  is  On  the  authorities  charged  with  the 
administration  of  the  national  system  of  public  vaccin- 
ation that  it  depends  (1)  to  maintain  continuously 
and  in  abundance,  wherever  this  can  be  done,  constant 
supplies  of  fresh  lymph,  and  (2)  to  make  the  super- 
fluous lymph  of  the  public  vaccinations  of  large  towns 
available  for  public  use  in  other  places,  and  for  private 
professional  use  throughout  the  kingdom. 

57.  Arrangements  in  Large  Towns. — Wherever 
large  numbers  of  children  can  be  brought  together  in 
regular  succession,  stocks  of  fresh  active  lymph  can  be 
maintained  with  the  greatest  ease,  and  the  abundance 
of  supply  is  proportionate,  of  course,  to  the  number  of 
children.  Hence,  while  an  average  of  ten  cases  on  a 
vaccinating  day  has  been  stated  to  be  the  minimum 
below  which  no  station  ought  to  be  expected  to  main- 
tain a  constant  fresh  supply,  it  is  of  great  consequence 
that,  wherever  practicable,  a  larger  attendance  of  cases 

(1)  That,  except  at  times  when  there  is  immediate  danger 
of  small-pox,  vaccination  be  not  appointed  to  he  performed  at 
any  station  oftener  than  once  a  week  ; 

(2)  That,  except  at  times  when  there  is  immediate  danger 
of  small-pox,  or  for  special  reason  in  individual  cases,  vaccina- 
tion in  town  districts  (unless  it  be  of  private  patients)  be  per- 
formed only  at  the  public  station  ; 

(3)  That,  as  opportunity  offers,  especially  in  urban  unions 
and  parishes,  all  unnecessary  subdivision  of  public  vaccina- 
tion among  many  districts  or  stations  be  discontinued ;  and 
that  in  populous  towns,  unless  under  special  circumstances, 
subdivision  be  not  made  beyond  the  point  where  each  vaccina- 
ting station  will  have  annually  at  least  500  applicants  for 
vaccination. 


148  HANDBOOK  OF.  VACCINATION. 

should  be  obtained.  If  the  unfortunate,  and  in  its 
results  mischievous,  system  of  subdivision  which  has 
heretofore  existed  in  the  arrangements  for  public  vaccin- 
ation in  the  towns  of  England  (see  Chap.  XV.)  were 
abolished,  it  would  be  found  that  in  the  denser  parts 
of  the  metropolis,  and  of  such  towns  as  Liverpool, 
Manchester,  Birmingham,  Leeds,  Sheffield,  Bristol,  etc., 
stations,  at  each  of  which  the  annual  vaccinations  should 
range  from  1000  to  1500,  could  readily  be  maintained 
without  any  disregard  of  the  public  convenience  as  to 
distance.  London  alone  would  supply  a  large  number 
of  such  stations  within  a  quarter  of  a  mile  of  nearly 
every  house,  and  within  a  third  of  a  mile  of  every 
house.*  Many  stations  much  more  frequented  than 
this  existed  before  the  introduction  of  "  Public  Vaccin- 
ation, "f  but  there  are  not  now  more  than  three  or 
four  in  the  kingdom  at  which  the  average  annual  vac- 
cinations amount  to  a  thousand.  In  the  official  visits 
which,  in  the  course  of  the  last  seven  years,  I  have 
repeatedly  made  to  the  principal  vaccinating  stations 
in  England,  I  have  had  ample  opportunities  of  noticing 

*  That  is,  in  its  central  and  most  thickly-peopled  parts  ;  this 
was  ascertained  by  Dr.  Buchanan  and  myself  in  the  in- 
quiry we  made  into  the  public  vaccination  of  London,  by  di- 
rection of  the  Privy  Council,  in  1863.  In  parts  in  which 
population  was  less  dense,  including  the  populous  suburbs, 
stations  at  the  same  distance  apart  would  still  have  from  500 
to  1000  cases  a  year.  It  was  only  in  the  outskirts  that  the 
stations  would  have  smaller  attendances,  or  need  to  be  placed 
farther  asunder.  (See  Sixth  Rep.  Med.  Off.  of  Privy  Coun- 
cil, p.  118.) 

f  At  the  Small-pox  Hospital  the  annual  vaccinations  were 
above  3000,  so  also  at  Surrey  Chapel ;  at  the  Birmingham  Dis- 
pensary there  were  between  2000  and  3000,  etc.  etc. 


ARRANGEMENTS  FOR    VACCINATION.        149 

the  very  great  advantages  these  few  larger  stations 
had  over  those  at  which  the  above-stated  minimum 
number  of  500  annual  cases  was  merely  attained,  or 
only  a  little  exceeded — whether  in  regard  to  their  op- 
portunities of  selection,  their  assurance  of  a  fair  attend- 
ance of- subjects  in  unfavorable  weather,  or  their  much 
larger  means  of  supplying  lymph  for  the  use  of  others. 
Wherever  they  exist,  the  local  population  is  greatly 
the  gainer  by  them.  And  their  national  importance 
cannot  be  overrated.  It  is  on  them  exclusively,  if  a 
proper  number  of  them  were  provided,  that  reliance 
should  be  placed  for  obtaining  that  large  fund  of  fresh- 
stored  lymph  which  needs  to  be  constantly  kept  on 
hand  by  the  National  Vaccine  Establishment,  for  the 
use  of  practitioners,  public  or  private,  in  the  small 
towns  and  rural  districts  of  the  kingdom,  as  well  as 
for  other  public  or  professional  needs.  The  stations 
at  which  the  annual  vaccinations  fall,  on  an  average, 
below  a  thousand,  and  especially  those  at  which  they 
nearly  fall  down  to  the  prescribed  minimum — the  sta- 
tions, in  fact,  under  a  proper  system,  of  the  less  dense 
parts  of  towns  of  the  first  magnitude,  and  the  stations 
of  moderate-sized  towns — would  not  then  be  needed, 
or  would  only  exceptionally  be  needed,  to  contribute 
to  the  national  stores,  and  might  be  reserved  for  the 
supply  of  local  professional  wants.  It  is  only  in  the 
very  largest  towns  that  these  first-class  stations  (such 
I  call  those  the  vaccinations  at  which  amount  to  a 
thousand  a  year)  could  be  obtained ;  but  every  town 
in  the  kingdom,  of  40,000  inhabitants,  and  many  towns 
of  smaller  population  than  this,  yield  annually  a  suffi- 
cient number  of  subjects  for  public  vaccination  to  main- 
tain a  station  at  which  the  performance  of  arm-to-arm 


150  HANDBOOK  OF   VACCINATION. 

vaccination  with  selected  lymph  might  be  placed 
weekly  within  the  reach  of  the  inhabitants,  and  at 
which  a  continuous  stock  of  lymph  fresh  from  the  arm 
might  be  kept  up.  If  at  present,  in  such  towns,  a 
large  amount  of  the  vaccination,  and  even  of  the  public 
vaccination,  is  done,  as  we  know  it  is,  with  stored  and 
conveyed  lymph,  to  the  great  detriment  of  the  public, 
it  is  because  the  advantages  which  number  and  aggre- 
gation of  population  give  have  not  been  duly  consid- 
ered— have,  in  fact,  been  thrown  away ;  and  the  public 
cases,  instead  of  being  kept  together,  have  been  so  dis- 
persed in  various  ways,  that  the  maintenance  of  a  local 
fresh  lymph  supply  became  impossible.  (See  postea, 
§61.) 

I  venture,  then,  to  think  that  if  the  authorities  will 
do  away  with  the  present  superfluous  appointments 
and  the  excessive  subdivision  in  towns,  and  so  divide 
or  distribute  the  public  performance  of  vaccination  in 
England  that  the  public  stations  in  the  denser  parts  of 
towns  of  great  magnitude  shall  be  supplied  with  an 
average  of  at  least  twenty  cases  on  each  vaccinating 
day ;  and  in  the  less  dense  parts  of  such  towns,  and  in 
towns  which,  though  smaller,  can  yet  furnish  cases 
enough  properly  to  maintain  continuous  arm-to-arm 
vaccination  with  an  average  approaching  that  number 
as  far  as  population  and  other  local  circumstances  ad- 
mit— the  following  advantages  would  be  derived:  (1) 
the  necessity  of  any  use  whatever  of  preserved  or  con- 
veyed lymph  in  the  public  vaccination  of  the  town 
(with  rare  exceptions  for  special  reasons  in  some  indi- 
vidual cases)  would  be  obviated  altogether — and  in 
effect  (inasmuch  as  public  vaccination  is  a  public  right, 
open  to  all)  no  necessity  would  exist  in  the  town  for 


" ARRANGEMENTS  FOR    VACCINATION.        151 

the  use  of  such  lymph  at  all,  except  in  so  far  as  parents 
preferred  not  to  avail  themselves  of  the  public  station; 
(2)  in  the  cases  in  which  parents  desired  to  have  the 
vaccination  performed  by  their  own  medical  attendants, 
there  would  be  furnished  on  the  spot  to  the  private 
practitioners  of  the  town  (who,  however  methodical  in 
the  arrangement  of  their  own  cases,  must  still,  from 
limited  numbers,  be  more  or  less  frequently  obliged, 
unless  they  had  recourse  to  long-stored  lymph,  to  seek 
assistance  from  without)  the  aid  they  require,  and  in 
the  most  effective  manner,  viz.,  with  lymph  perfectly 
fresh  ;*  and  (3)  the  lymph,  which  must  necessarily  be 

*  What  an  absurdity,  what  a  gross  absurdity,  it  is,  that  in 
such  towns  as  (say)  Hull,  or  Bradford,  or  Nottingham,  or 
York  (and  I  might  name,  indeed,  nearly  all  the  large  towns 
in  the  kingdom),  a  practitioner,  instead  of  having  in  his  own 
town  a  station  at  which  on  the  appointed  week-day  he  might 
always  be  supplied  with  lymph  straight  from  the  arm,  should 
either  be  obliged  to  send  about,  first  to  one  place  or  neigh- 
bor, and  then  to  another,  to  beg  some  lymph — which  often 
cannot  be  got,  and  often  if  it  be  got  is  of  some  length  of  stor- 
age— or  be  obliged  to  send  up  to  London  to  the  National  Vac- 
cine Establishment,  whence  the  lymph  sent  out  to  him  must 
at  the  earliest  be  a  day  or  two  old,  and  frequently  necessarily 
older.  From  the  towns  Thave  named,  and  others  as  large  or 
larger,  applications  to  the  National  Vaccine  Establishment 
are  of  weekly  occurrence.  Contrast  with  these  places  a  few 
others  where  proper  arrangements  exist,  and  where  a  local 
practitioner  is  not  only  sure  of  obtaining  fresh  from  the  arm 
the  lymph  he  wants,  but  where  the  public  vaccinator  (as  I 
have  myself  repeatedly  seen)  not  unfrequently  looks  out  for 
him  a  suitable  child,  the  parents  of  whom  are  willing  for  a 
small  douceur  to  accompany  him  to  his  patients'  residences,  so 
that  the  -operations  may  he  done  direct  from  arm  to  arm.  I 
would  take  this  opportunity  of  calling   the  attention  of  my 


152  HANDBOOK  OF  VACCINATION. 

kept  always  in  store  {but  which  should  always  be  as 
fresh  as  possible)  for  the  wants  of  small  towns  and  of 
rural  districts,  as  well  as  for  the  use  of  the  army  and 
navy,  the  colonies,  and  abroad,  would  be  supplied  of 
the  choicest  kind,  and  in  quantity  practically  unlimited. 
Under  such  arrangements  as  have  been  here  described, 
any  dearth  of  lymph  of  the  best  and  freshest  kind  must, 
I  conceive  (and  I  write  with  some  practical  knowledge 
of  the  subject),  be  at  any  time  utterly  impossible. 

58.  Arrangements  in  Smaller  Urban  Populations. 
— In  urban  populations  in  which  the  cases  for  public 
vaccination  fall  short — but  do  not  very  largely  fall 
short  —  of  the  number  assigned  as  the  minimum  for 
properly  carrying  on  continuous  arm-to-arm  vaccina- 
tion, in  which  (say)  there  is  but  an  average  of  seven 
or  eight  cases  a  week  instead  of  an  average  of  ten, 
weekly  public  vaccination  may  still  with  pains  be 
maintained,  without  the  necessity  for  recourse  to  pre- 
served lymph  (except  only  occasionally),  and  with  very 
fair  opportunities  of  selection.  A  good  deal  of  con- 
trivance, however,  has  often  to  be  resorted  to  for  the 
purpose,  the  difficulties  increasing  as  the  number  of 
cases  diminishes,  but  in  a  much  greater  ratio.  Public 
vaccinators,  under  such  circumstances,  require  to  be 
watchful  that  their  lymph  does  not  deteriorate,  and, 

professional  brethren  to  the  great  mutual  advantages  I  have 
always  found  attending  a  good  understanding  between  the 
public  vaccinator  and  the  private  practitioners  of  a  town,  the. 
latter  sending  to  the  public  station  such  of  their  patients  as 
pay  them  no  fee  for  vaccination,  or  doing  what  they  can  to 
induce  them  to  go  there,  and  the  former  in  return  being 
ready,  and  justly  considering  that  under  the  circumstances 
there  is  a  claim  on  him,  to  give  the  assistance  above  stated. 


ARRANGEMENTS  FOR    VACCINATION.        153 

though  they  may  frequently  be  able  to  assist  their 
brethren  in  private  practice,  they  are  not  to  be  counted 
on  for  being  able  to  do  so  at  any  and  all  times,  as  in 
larger  towns.  What  is  the  lowest  annual  number  of 
cases  with  which  a  practitioner  may  advantageously 
attempt  to  carry  on  continuous  weekly  vaccination, 
depends  greatly  on  the  pains  he  takes  in  methodical 
arrangement,  and  on  his  judgment  in  his  individual  se- 
lections. Hence,  sometimes,  vaccinators  with  limited 
numbers  are  found  maintaining  better  stations  than 
others  who  have  larger  opportunities.  But,  as  a  rule, 
my  experience  would  lead  me  to  think  it  of  disadvant- 
age, if  attempt  were  made  to  carry  on  a  public  station 
weekly  throughout  the  year  where  the  annual  number  of 
cases  fell  at  all,  or  at  all  events  if  it  fell  much,  below  300. 
59.  Arrangements  in  still  Smaller  Towns,  and  in  Eu- 
ral  Districts. — Wherever  the  number  and  distribution 
of  cases  for  public  vaccination  is  such,  as  it  must  be  in 
all  small  towns  and  rural  districts,  that  a  continuous 
weekly  succession  of  applicants  in  sufficient  number  at 
a  station  cannot  be  maintained,  the  best  mode  of  pro- 
viding good  arm-to-arm  vaccination  for  the  public  con- 
sists in  the  adoption  of  some  form  of  periodical  vaccin- 
ation. Thus,  public  vaccination  might  be  carried  on 
during  the  summer  months  only,  and  suspended  during 
the  winter  months.  In  a  town  which  will  give  (say) 
its  200  cases  a  year  to  a  public  vaccinator — a  number 
quite  insufficient  to  keep  a  station  always  going — vac- 
cinations may  very  well  be  kept  up  weekly  throughout 
the  summer.  Where  population  is  smaller  or  more 
scattered,  the  vaccination  should  be  carried  on  for  a 
few  successive  weeks  at  two  or  three  periods  in  the 
year.     The  best  provision  for  rural  districts,  including 

14 


154  HANDBOOK  OF   VACCINATION. 

the  small  towns  of  such  districts,  consists  in  the  system- 
atic sweeping  of  the  district  (if  I  may  be  allowed  the 
expression)  every  spring  and  autumn.  In  laying  out 
arrangements  for  periodical  vaccination  in  districts  of 
this  kind,  with  a  view  to  the  performance  of  the  vaccin- 
ation, as  far  as  possible,  from  arm  to  arm,  local  authori- 
ties should  (1)  appoint  as  few  stations  as  is  consistent 
with  due  regard  to  the  convenience  of  the  population 
as  to  distance,  (2)  consider  in  reference  to  each  station 
what  is  the  number  of  cases  to  be  annually  provided 
for  thereat,  and  (3)  so  fix  the  attendances  of  the  vaccin- 
ator that,  as  a  rule,  there  shall  be  several  children  as- 
sembled for  each  attendance.  In  periodical  vaccina- 
tions, the  vaccinator  has  only  to  provide  himself  from 
without  with  lymph  for  the  commencement  of  the  peri- 
odical proceedings.  He  gets  lymph  for  the  vaccination, 
say,  of  three  well-chosen  children ;  from  them,  or  from 
one  or  other  of  them,  he  is  able  to  vaccinate  his  first 
group,  who  yield  him  lymph  not  only  wherewith  to 
continue  his  arm-to-arm  work,  but  for  use  fresh-stored, 
in  those  cases  in  which  the  use  of  preserved  lymph  may 
be  indispensable.  No  arrangements  that  can  be  devised 
for  rural,  or  for  any  little  populated  districts,  will 
obviate  altogether  the  necessity  for  the  occasional  use 
of  lymph  stored  or  conveyed:  but  what  may  and 
should  be  done,  is  to  reduce  this  necessity  to  a  mini- 
mum. And  we  know  from  experience  that  in  rural 
districts,  by  steady  adhesion  of  the  vaccinator  to  peri- 
odical station al  arrangements,  the  inhabitants  may  en- 
joy, with  few  exceptions,  the  advantages  of  well-per- 
formed arm-to-arm  vaccination.  Under  the  Vaccination 
Laws  recently  in  force,  the  establishment  of  a  good 
periodical  system  of   public  vaccination   in   districts 


ARRANGEMENTS  FOR    VACCINATION.        155 

which  required  it  was  not  practicable.  It  would  have 
liccii  clearly  inconsistent  with  a  law  which  enacted, 
under  penalty,  that  all  children  (health  permitting-) 
should  be  vaccinated  within  three  months  of  birth,  that 
public  vaccination  should  in  any  district  be  suspended 
for  three>  four,  or  six  months  together.  But  by  the 
"Vaccination  Act,  186?,"  it  is  expressly  provided  that, 
in  those  districts  in  which  the  paucity  or  diffusion  of 
population  renders  it  expedient  that  public  vaccination 
should  only  be  carried  on  at  intervals  exceeding  three 
months,  parents  shall  be  exempt  from  any  penalty  for 
neglect  arising  during  an  interval,  on  condition  that 
the  vaccination  be  performed  during  the  next  periodical 
attendance  of  the  public  vaccinator. 

60.  Arrangements  for  Private  Vaccination. — I 
have  but  few  hints  to  offer  with  regard  to  the  conduct 
of  private  vaccination,  but  some  probably  may  be  ac- 
ceptable. The  principles  on  which  private  vaccination 
should  be  carried  on  are  of  course  essentially  the  same 
as  those  recommended  for  public  vaccination.  There 
are  scarcely  any  private  practitioners  whose  cases  are 
numerous  enough  to  enable  them  to  maintain  stocks  of 
lymph  of  their  own  for  any  long  time  together,  and 
most  private  vaccination  has  to  be  done  periodically, 
or  in  batches.  Extraneous  assistance  must  be  given 
for  the  commencement  of  each  batch,  but  the  practi- 
tioner, having  received  this  assistance  to  start  with, 
should  endeavor  so  to  arrange  his  cases  as  to  keep  up 
his  own  supply  until  the  batch  requiring  vaccination  is 
exhausted.  I  find  many  practitioners,  in  their  desire 
to  maintain  a  stock  of  their  own  as  long  as  possible,  re- 
ducing their  weekly  vaccinations  to  an  inconveniently 
low  number — taking  care,  in  fact,  not  to  vaccinate  above 


156  HANDBOOK  OF    VACCINATION. 

a  case  or  two  a  week.  I  venture  to  suggest  that  this 
is  an  undesirable  arrangement,  and  one  that  often  de- 
feats its  own  object.  If  a  practitioner  has  twenty  cases 
on  his  list  to  vaccinate,  he  will  do  them  more  easily, 
and  more  satisfactorily,  if  he  vaccinate  them  all  in  two 
or  three  successive  weeks,  than  if  he  try  to  eke  out  his 
vaccination  for  five,  or  six,  or  seven  weeks,  or  more. 
In  the  upper  and  upper-middle  classes  of  society  it  is 
usual  to  perform  the  vaccination  at  the  patients'  dwell- 
ings ;  but,  where  this  has  to  be  done,  it  is  always  de- 
sirable that  a  child  fit  for  transferring  the  lymph  should 
be  taken  to  the  house.  Practitioners  have  not,  gener- 
ally, much  trouble  in  getting  most  of  their  lower-mid- 
dle class  patients  to  attend  at  their  surgery.  Parents 
are  generally  very  ready  to  do  this  when  they  know 
that  it  is  for  an  object  beneficial  to  the  child :  and  the 
surgery  attendances  of  course  should  be  regulated  in 
weekly  succession.  In  all  large  towns  where  continu- 
ous weekly  public  vaccination  can  be  maintained  (§  51), 
fresh  lymph  should  be  procurable  by  the  private  prac- 
titioners at  the  station  of  the  town,  to  enable  them  to 
commence  their  proceedings  when  several  cases  have 
accumulated  for  vaccination.  Practitioners  in  other 
places  could  always  obtain  it  for  the  same  purpose,  as 
at  present,  from  the  National  Establishment. 

61.  Results  of  Disregard  of  the  foregoing  Consider- 
ations.— I  have  felt  the  more  anxious  to  make  clearly 
understood  the  sort  of  arrangements  upon  which  reli- 
ance may  be  placed  for  securing  good  lymph  supply, 
and,  as  far  as  possible,  the  performance  of  arm-to-arm 
vaccination,  because,  in  the  discharge  of  my  official 
duties,  I  witness  daily  the  unfortunate  results  which 
have  ensued  from  the  adoption  of  quite  other  arrange- 


ARRANGEMENTS  FOR    VACCINATION.        157 

merits  for  the  performance  of  public  vaccination — ar- 
rangements in  which  these,  the  matters  of  first  conse- 
quence, have  been  overlooked  or  disregarded.  It  seems 
scarcely  credible,  but  it  is  nevertheless  true,  that  in 
this  densely-peopled  metropolis,  where,  if  anywhere, 
there  should  be  every  facility  for  affording  to  children 
invariably  the  benefit  of  the  best  arm-to-arm  vaccina- 
tion, a  large  proportion  even  of  the  public  vaccination 
should  be  done  with  stored  lymph,  or  done  from  the 
arm  under  conditions  that  admit  of  no  proper  selection 
of  lymph  being  made  ;*  that  in  some  districts  of  London 
more  than  half  the  public  vaccination,  and  in  others 
even  a  much  larger  proportion,  should  be  so  done ;  that 
in  most  of  the  large  towns  of  England  the  same  evils 
should  be  found  extensively  to  exist ;  and  that,  in  many 
of  them,  not  only  is  public  vaccination  with  stored 
lymph  the  rule,  instead  of  being  (what  in  such  places 
it  should  be)  the  very  rare  exception,  but  the  perform- 
ance of  public  vaccination  at  all  is,  in  some  of  the  dis- 
tricts into  which  the  towns  have  been  divided,  at  times 
suspended   for    months   together."}"      The    Poor-Law 

*  It  was  only  the  other  day  that  a  public  vaccinator  of  one 
of  the  most  densely-peopled  parishes  of  London  told  me  that, 
from  his  small  number  of  cases,  he  must  sometimes  vaccinate 
from  second-rate  arms,  or  he  could  not  do  it  from  tbe  arm  at 
all ;  the  public  vaccinators  of  this  parish  were  fivefold  as 
many  as  there  should  have  been  to  keep  up  proper  supplies. 

f  See  fuller  illustrations  in  the  concluding  section  of  Chap- 
ter XV.;  also,  the  successive  Annual  Keports  of  the  Medical 
Officer  of  the  Privy  Council  (Appendices  containing  Results 
of  Local  Inquiries  as  to  Vaccination),  iii.-vii.  inclusive,  and 
particularly  the  Sixth  Report,  in  which  is  included  the  results 
of  an  inquiry,  made  by  Dr.  Buchanan  and  myself,  into  public 
vaccination  in  the  metropolis. 

14* 


158  HANDBOOK  OF   VACCINATION. 

Board  will  henceforth  be  able  to  put  an  end  to  that 
multiplication  of  districts,  and  multiplication  of  appoint- 
ments, which  have  been  the  main  causes  of  these  re- 
sults. And  the  provisions  which  have  been  introduced 
for  that  purpose  into  the  New  Yaccination  Act — pro- 
visions which  give  to  the  central  authorities  regulative 
and  controlling  powers  which  they  have  not  heretofore 
had — will,  there  can  be  no  doubt,  soon  lead  to  the  sub- 
stitution of  arrangements  more  advantageous  to  the 
public. 


CHAPTER    VIII. 

OP   THE   CONVEYANCE   AND   STORAGE   OP   LYMPH. 

62.  Conveyance  and  Storage  of  Lymph. — After  all 
has  been  done  that  can  possibly  be  done  for  giving  the 
population  the  benefits  of  arm-to-arm  vaccination,  there 
will  still  be  frequent  occasions  on  which  recourse  must 
be  had  to  conveyed  or  stored  lymph.  Everywhere  in- 
dividual cases  will  be  met  with  in  which  it  may  be  re- 
quired ;  and  it  must  be  kept  ready  on  a  large  scale,  to 
meet  the  wants  of  those  who  are  unable  to  maintain 
their  own  supplies — e.g.  for  starting  periodical  public 
vaccinations,  for  starting  series  of  private  vaccinations, 
for  the  use  of  the  public  services  in  the  army,  navy, 
etc.,  and  for  transmission  to  the  colonies  and  to  other 
foreign  places,  where,  from  paucity  of  subjects  and 
climatic  or  other  causes,  stocks  of  lymph  cannot  be 
maintained,  or  require  at  times  to  be  renewed.     The 


STORAGE   OF  LYMPH.  159 

best  modes  of  conveying  and  storing  lymph  demand, 
then,  our  most  attentive  consideration. 

63.  Modes  of  Conveyance  for  Immediate  Use. — For 
mere  conveyance  of  lymph  from  one  house  to  another, 
some  practitioners  use  their  ordinary  vaccinating  lan- 
cets, charging  the  points  of  them  well,  and  keeping 
the  blades  from  contact  with  the  handles  by  a  strip  of 
paper  folded  as  a  shield  round  the  base ;  or  they  use 
lancets  specially  constructed  so  as  not  to  admit  of  the 
blade  coming  into  contact  with  the  handles.  For  im- 
mediate, or  for  very  prompt  use,  this  will  do  very  well, 
but  the  lymph  on  the  lancet-points  soon  concretes,  and 
the  drier  it  is  allowed  to  get  the  greater  are  the  chances 
of  failure ;  besides  which  any  attempt  to  keep  lymph 
on  lancets  beyond  a  day  or  two  is  at  the  risk  of  its 
spoiling  and  decomposing.  When  lancets  are  em- 
ployed for  conveying  lymph,  the  utmost  care  is  requi- 
site to  prevent  them  from  getting  rusty,  and  usually 
lancets  so  employed  do  not  remain  long  fit  for  use. 
The  state  of  rust  in  which  I  have  repeatedly  seen  lan- 
cets sent  by  practitioners  to  vaccinating  stations  to  be 
charged,  assures  me  that  a  caution  in  this  respect  is 
much  needed,  and  no  doubt  to  this  carelessness  are 
traceable  not  a  few  sore  arms.  To  make  sure  of  suc- 
cess in  using  charged  lancets,  the  practitioner  should 
allow  for  each  insertion  he  makes,  the  charge  collected 
on  one  lancet.  And  if  he  is  not  able  to  perform  his 
vaccination  on  the  day  on  which  the  lymph  is  taken, 
he  should  not  use  the  lancets  at  all,  but  wash  off  the 
lymph  and  clean  the  instruments  well. 

A  better  way  of  conveying  lymph  in  a  fluid  state  for 
prompt  use,  is  the  vaccine  bottle — a  small  square  bottle 
with  a  well-ground  glass  stopper,  so  shaped  that  its 


160  HANDBOOK  OF   VACCINATION. 

inner  surface  projects  into  the  bottle,  in  the  form  of  an 
oblong  blade  of  glass,  on  which  the  lymph  is  collected. 
Or  the  lymph  may  be  carried  between  two  fiat,  closely- 
fitting  bits  of  glass,  each  about  three- 
quarters  of  an  inch  square — one  of 
which  bits  may,  if  the  practitioner 
chooses,  be  furnished  with  a  cup-like 
depression  at  its  centre.  In  either 
case,  the  lymph  must  be  used  within 


twenty-four  hours,  or,  if  the  weather  be  cold  and  the 
bottle  or  glasses  have  been  kept  in  a  cool  place,  within 
thirty-six,  or  at  the  utmost  forty-eight  hours  of  being 
taken.  Lymph,  like  other  moist  animal  matter  that 
has  access  to  air,  soon  undergoes  changes  which  ren- 
der it  unfit  for  use,  and  the  prudent  practitioner  will 
never  attempt  to  keep  it  in  a  liquid  state  longer  than 
the  time  above  specified,  except  in  hermetically  sealed 
tubes.  I  think  it  scarcely  necessary  to  advert,  except 
for  the  sake  of  deprecating  it,  to  the  proposal  which 
has  been  made  of  keeping  lymph  liquid  for  a  longer 
time  by  mixing  it  with  glycerin.  What  effect,  if  any, 
glycerin  might  have  in  retarding  the  decomposition  of 
lymph,  I  have  not  thought  it  worth  while  to  inquire : 
because  it  is  with  lymph — pure  lymph,  as  pure,  as  con- 
centrated, and  as  pungent  as  can  be — that  we  should 
vaccinate,  not  with  mixtures  and  compounds.  But  I 
happen  to  be  acquainted  with  some  results  of  using 
the  mixture,  and  they  exhibited,  as  might  be  expected, 
a  large  relative  amount  of  failure. 

64.  Various  Modes  of  Storage. — Lymph  that  is  to 
be  kept  beyond  the  times  above  stated  before  being 
used  should  be  dried  and  kept  in  a  dry  state  on  points 


STORAGE   OF  LYMPII.  101 

or  on  glasses,  or  should  be  preserved  liquid  in  capillary 
tubes  hermetically  sealed. 

(a)  Points. — The  points  used  for  preserving  lymph 
are  made  of  ivory.  Old  ivory  should  be  used,  as  being 
less  absorbent.    They  are  generally  cut  of  this  size  and 

shape,  or   scarcely  so   big,  but     

much   larger   points   would   be      /  ^> 

far  preferable,  and  best  of   all 

are  such  points  as  Ceely,  Marson,  and  others  have 
had  made  for  their  own  use,  which  have  the  size  and 
shape  of  the  ordinary  lancet—rare,  in  fact,  ivory  lancets. 
This  size,  no  doubt,  would  be  inconvenient  for  trans- 
mitting lymph,  but  I  know  no  reason  why  much  larger 
points  than  the  present  should  not  be  used.  For  charg- 
ing the  points,  the  vesicles  are  opened  according  to  the 
directions  given  when  lymph  is  to  be  taken  from  the 
arm  for  a  direct  vaccination  (§  50,  c,  1),  and  the  points 
well  dipped  in  the  exuded  lymph  till  a  good  drop  stands 
on  each  of  them ;  they  should  then  be  laid  on  some  flat 
raised  surface,  as  the  edge  of  a  book  (but  so  that  their 
wet  ends  do  not  touch  it),  to  dry;  and  if,  when  they 
have  undergone  some  drying,  any  should  appear  insuf- 
ficiently coated,  these  should  be  redipped.  Under  any 
circumstances,  indeed,  a  second  coating  is  most  desir- 
able; and  a  third  coating  will  make  them  take  all  the 
more  surely.  It  is  not  only  the  ends  of  the  points,  but 
some  considerable  part  of  their  flat  surface,  which 
should  be  coated.  Under  the  disadvantages  in  which 
a  practitioner  is  placed  who  has  to  use  preserved 
lymph  on  points,  care  should  be  taken  to  give  him  as 
abundant  a  supply  of  it  on  each  point  as  possible. 
When  the  points  have  dried  they  should  be  wrapped 
up  in  oil  silk,  which  must  be  tightly  closed  with  gum ; 


162  HANDBOOK  OF   VACCINATION. 

they  should  then  be  put  away  in  a  dry  place,  in  a  well- 
corked  bottle  full  of  cotton-wool,  or  else  they  should 
be  sent  off  to  their  destination,  if  they  are  to  be  sent 
away.  Points  charged  from  the  arms  of  different 
children  should  not  be  mixed  together,  and  on  each  set 
of  points  should  be  noted  the  source  (the  particular 
child)  from  which  the  lymph  was  taken. 

(b)  Glasses. — The  glasses  which  are  used  for  storing 
lymph  are  the  same  square  closely-fitting  bits  of  glass 
already  described  as  sometimes  used  for  conveying 
moist  lymph.  When  the  lymph,  however,  is  to  be  dry- 
stored,  both  of  the  plates  must  be  flat  and  free  from  cup- 
like depression.  First  one  square,  and  then  another, 
is  dipped  and  redipped  in  the  lymph  which  stands  on 
the  surface  of  an  opened  vesicle  till  they  are  found  to 
be  well  coated ;  the  lymph  must  then  be  allowed  to 
concrete,  and  the  coated  surfaces  of  the  squares  pressed 
very  close  together.  Successive  pairs  of  glasses  may 
be  treated,  of  course,  in  the  same  way :  each  pair  should 
be  wrapped  up  in  oil  silk  or  tinfoil,  and  put  by  for  use  ; 
the  source  of  the  lymph,  as  in  the  case  of  points,  being 
always  noted  upon  it.  Glasses  should  be  so  coated 
that  when  they  are  held  to  the  light  the  inspissated 
lymph  should  be  very  visible. 

(c)  Tubes.  —  Capillary  tubes,  or  tubes  that  were 
called  capillary,  were  of  very  early  employment  for 
collecting  and  preserving  lymph ;  but,  probably  from 
the  nicety  that  attaches  to  the  use  of  them,  and  the  dif- 
ficulty often  experienced  in  filling  them  if  the  bore  be 
not  really  capillary,  another  form  of  tube,  tapering  in 
shape  and  bulbed  at  the  extremity,  came  into  use,  and 
almost,  if  noj  quite,  superseded  them  for  a  time.  The 
bulb  was  warmed  in  the  hand,  in  the  mouth,  or  by  a 


STORAGE  OF  LYMPH.  163 

flame,  so  as  to  rarefy  the  air  within  the  tube,  the  open 
extremity  of  which  was  then  plunged  into  the  lymph 
as  it  stood  on  the  surface  of  a  vesicle  previously  opened ; 
when  the  lymph  had  risen  in  the  tube  as  far  as  it  would 
rise,  the  open  end  was  hermetically  sealed.  This  kind 
of  tube  was  objectionable  on  account  of  the  amount  of 
air  which  always  remained  in  the  bulb,  and  it  is  now 
no  longer  employed.  The  only  tubes  now  in  use  are 
the  plain  straight  tubes  of  capillary  bore.  The  profes- 
sion is  much  indebted  to  Dr.  Husband,  of  Edinburgh, 
for  the  pains  he  has  taken  to  perfect  this  mode  of  col- 
lecting and  preserving  lymph,  and  I  cannot  do  better 
than  give  an  account  of  it  in  his  own  words  : 

"The  tube  employed  is  simple,  straight,  cylindrical, 
open  at  both  ends,  and  of  such  dimensions  as  to  fulfill 
the  following  conditions,  upon  which  it  will  be  found 
that  its  peculiar  value,  as  a  means  for  preserving  lymph 
for  future  everyday  use,  essentially  depends.  It  must 
be, — 

"1.  In  the  first  place,  of  such  tenuity  that  it  can  be 
sealed  instantaneously  at  the  flame  of  a  candle. 

"  2.  In  the  second  place,  large  enough  to  contain  as 
much  lymph  as  is  sufficient  for  one  vaccination. 

"  3.  In  the  third  place,  long  enough  to  admit  of  both 
ends  being  sealed  hermetically  without  subjecting  the 
charge  to  the  heat  of  the  flame. 

"4.  And,  in  the  fourth  place,  of  such  strength  as  not 
to  break  easily  in  the  mere  handling. 

"  There  need  be  no  difficulty  in  procuring  tubes  which 
perfectly  answer  this  description,  only  they  must  be 
made  according  to  a  certain  standard,  which  obviously, 
from  the  very  nature  of  the  case,  is  not  an  arbitrary 
one,  admitting  of  being  altered  to  suit  the  notions  of 


164  HANDBOOK  OF   VACCINATION. 

different  individuals,  but  one  concerning  which,  within 
certain  limits,  there  can  be  no  dispute  nor  difference  of 
opinion.* 

"The  following  is  the  mean  of  several  measurements 
which  I  have  made  of  tubes,  differing  somewhat  in  size, 
but  all  of  them  capable  of  containing  a  sufficient  charge 
of  lymph,  and  of  being  sealed  instantaneously,  at  the 
flame  of  a  candle,  without  subjecting  the  contained 
charge  to  the  heat,  and  also  strong  enough  to  bear  all 
necessary  manipulations  without  breaking  : 
Average  length,  2|  to  3  inches. 
Diameter,  ^-th  of  an  inch. 
Thickness  of  wall,  T|^th  of  an  inch. 

"  If  any  one  be  disposed  to  find  fault  with  these  meas- 
urements, and  to  prefer  tubes  differently  proportioned, 
I  have  no  objection,  provided  he  keep  in  view  the  neces- 
sity of  fulfilling  the  required  conditions.  The  tubes 
need  not  strictly  and  rigidly  conform  to  the  standard 
laid  down,  but  they  must  not  vary  from  it  except 
within  certain  limits,  otherwise  they  become  unfit  for 
their  purpose. 

"Although  their  normal  shape  is  cylindrical  (fig.l, 
c,  T,)  some  of  them  are  more  or  less  fusiform  toward 
one  extremity,  and  terminate  there  in  a  fine  point  (fig. 
1,  c',  y'),  or  one  of  the  extremities  may  taper  to  a 
point  without  becoming  fusiform  (fig.  1,  c",  y").     In 


*  This  standard  is  not  always  adhered  to  as  it  ought  to  he, 
by  the  instrument-makers,  partly  owing  to  the  conflicting  or- 
ders given  them  hy  different  persons,  and  hence  large  quan- 
tities of  tubes  are  at  this  moment  in  circulation  which,  being 
much  too  large  to  be  manageable,  give  a  very  erroneous  idea 
of  the  method. 


STORAGE  OF  LYMPH.  Ifi5 

either  case  this  departure  from  the  regular  form  is  acci- 
dental, and,  as  will  appear  presently,  is  no  disadvant- 
age, but  rather  the  contrary. 


Y- 
Yl 


=^C 


Fia.  1. 

"  Having  thus  described  the  instrument  itself,  I  come 
now  to  the  mode  of  using  it. 

"  The  vesicles  having  been  opened  with  a  lancet  in 
the  usual  way,  the  tube,  held  in  a  position  more  or  less 
inclined  to  the  horizontal,  is  charged  by  applying  one 
end  of  it  (the  straight  end,  if  they  be  not  both  straight) 
to  the  exuding  lymph,  which  enters  immediately  by  the 
force  of  capillary  attraction.  Allow  as  much  to  enter 
as  will  occupy  from  about  one-seventh  to  one-half  the 
length  of  the  tube,  according  as  its  capacity  is  greater 
or  less.  As  a  general  rule,  each  tube  should  not  be 
charged  with  more  than  will  suffice  for  one  vaccina- 
tion. 

"  It  is  now  to  be  sealed  in  one  or  other  of  the  follow- 
ing ways: 

"  Either,  1st,  make  the  lymph  gravitate  toward  the 
middle  by  holding  the  tube  vertically  and  giving  it 
a  few  slight  shocks  by  striking  the  wrist  on  the  arm  or 
table ;  then  seal  the  end  by  which  the  lymph  entered 
by  applying  it  to  the  surface  of  the  flame  of  a  candle, 
or  any  similar  flame.  It  melts  over  and  is  sealed  im- 
mediately. 

15 


16G  HANDBOOK  OF   VACCINATION. 

"  Proceed  with  the  other  end  in  the  same  way,  but 
first  plunge  it  suddenly,  say  half  an  inch,  into  the  flame, 
and  as  quickly  withdraw  it  till  it  touches  the  surface, 
and  hold  it  there  till  it  too  melts  over.  It  is  necessary 
to  plunge  it  first  into  the  flame,  for  this  reason,  that  if 
it  be  once  applied  to  the  external  surface  of  the  flame 
it  melts  over,  no  doubt,  and  is  sealed ;  but  before  you 
have  time  to  complete  the  process,  and  while  the  glass 
is  still  soft,  the  contained  air  expands  with  the  heat, 
and  forms  a  minute  bulb,  which  either  gives  way  on 
the  instant,  rendering  it  necessary  for  you  to  break  off 
the  end  and  Commence  anew,  or,  what  is  still  worse, 
remains  entire  for  the  time,  only  to  break  afterward, 
in  consequence  of  its  extreme  tenuity  of  wall,  by  the 
lightest  touch.  Mr.  Ceely  has  suggested  that  while 
this  precaution  is  necessary  for  the  reason  stated,  it 
serves  also  to  expel  a  portion  of  air,  and  so  leaves  less 
air  to  be  sealed  up  along  with  the  fluid  lymph. 

"  Or  else,  secondly,  the  charge  having  entered,  hold 
the  tube  with  the  finger  and  thumb,  covering  the  inner 
extremity  (l)  of  the  column  of  lymph  (l,  y,  fig.  2),  and 
protecting  it  from  the  heat,  and  draw  nearly  the  whole 
of  the  empty  portion  (c,  l)  through  the  flame  so  as  to 
rarefy  the  contained  air,  and  in  withdrawing  it  seal  the 


YEip™ J " 


Fig.  2. 

further  extremity  (c).  The  column  now  passes  quickly 
along  toward  the  middle  of  the  tube  as  the  contained 
air  cools,  and  you  complete  the  process  by  sealing 
lascly  the  orifice  (y)  by  which  it  entered. 

"This  latter  method  answers  especially  well  when 


STORAGE   OF  LYMPH.  167 

the  tube  is  below  the  average  size,  or  has  the  form  (c, 
y)  in  which  the  opening  at  (c)  is  so  minute  that  it 
seals  over  in  the  merest  fraction  of  a  second. 

"It  should  be  observed,  that  in  no  case  is  a  tube  to 
be  laid  down  until  the  lymph  has  been  made  to  pass 
toward  the  middle  of  it,  for  the  fluid  concretes  quickly 
about  the  orifice,  and  you. cannot  afterward  detach  it 
without  difficulty :  but  if  it  be  at  once  made  to  pass 
away  from  the  orifice  by  holding  the  tube  vertically, 
you  may  lay  the  charge  down  and  take  half  a  dozen 
or  more  in  the  same  way  before  sealing  them ;  on'y  if 
you  delay  the  sealing  process  too  long,  more  than  five 
or  ten  minutes  perhaps  (a  delay  which  need  never  hap- 
pen), the  lymph  between  the  tube  is  apt,  from  evapo- 
ration, to  become  adherent,  especially  if  it  be  more  than 
ordinarily  viscid,  and  it  cannot  afterward  be  blown  out 
when  you  come  to  use  it. 

"  If  the  lymph  do  not  exude  freely,  the  tube  may  re- 
quire to  be  drawn  several  times  more  or  less  obliqaely 
across  the  surface  of  the  vesicle,  or  cluster  of  vesicles, 
until  a  sufficient  charge  has  entered ;  but  generally  if 
the  exudation  be  copious,  and  a  drop  of  some  size  has 
formed  before  you  begin  to  take  your  supply,  the  orifice 
of  the  tube  need  not,  indeed  ought  not,  to  touch  the 
surface,  but  is  merely  to  be  dipped  into  the  clear  fluid ; 
and  one  may  commonly  in  this  manner  from  one  infant's 
arm  charge  five  or  six  tubes  in  almost  as  many  seconds 
with  perfectly  pure  and  limpid  lymph,  which  shall  con- 
tain neither  epithelian  scales  nor  pus  globules  nor  blood 
disks,  and  therefore  be,  so  far,  in  the  best  possible  con- 
dition for  preservation. 

"In  order  to  obtain  the  lymph  from  a  tube  for  the 
purpose  of  vaccinating,  the  sealed  ends  are  broken  off, 


168 


HANDBOOK  OF   VACCINATION. 


and  the  contents  blown  out  gently  on  the  point  of  the 
lancet."* 

The  source  whence  the  lymph  is  taken  may  be  con- 
veniently indicated  by  attaching  a  piece  of  thin  writing- 
paper,  as  represented  in  fig.  3. 


Fig.  3. 

65.  Is  any  one  mode  of  Storage  preferable  to 
another? — The  question  whether  any  one  of  these 
modes  of  preserving  lymph  has  a  decided  superiority 
over  the  others,  is  difficult  to  determine.  Probably, 
under  different  circumstances  and  in  different  hands, 
each  has  its  advantages.  At  first  sight  it  might  appear 
that  the  lymph  in  capillary  tubes,  existing  apparently 
in  exactly  the  same  condition  as  at  the  moment  it  was 
taken  from  the  vesicle,  should  not  differ  materially  in 
its  efficacy  from  lymph  transferred  direct  from  arm  to 
arm;  but  this  is  far  indeed  from  being  the  case. 
Whether  it  be  that  the  heat  employed  in  the  process 
of  sealing  produces  some  action  upon  the  lymph,  or 
whether  by  keeping  in  the  liquid  state  it  is  liable  to 
undergo  molecular  changes,f  quite  certain  it  is  that 


*  Second  Ann.  Kep.  of  Medical  Officer  of  Privy  Council, 
p.  20. 

f  Whatever  the  changes  may  he  that  lymph  undergoes  by 
storage  in  capillary  tubes,  they  must  take  place  either  in  the 


STORAGE  OF  LYMPH.  1G9 

tube-vaccination  does  not  even  approach  the  success  of 
vaccination  from  arm  to  arm:  the  latter,  properly  per- 
formed, will  not  fail  above  once  in  150  times  (§  <59) ; 
but  with  tube-lymph,  in  Dr.  Husband's  own  hands, 
where  we  are  quite  sure  that  every  proper  precaution 
will  have  been  taken  both  in  the  collecting  the  lymph 
and  in  sealing  the  tubes,  the  failures  to  infect  are  as 
many  as  one  in  ten.  MM.  Bousquet  and  Bourdin,  in 
many  comparative  experiments,  found  that  tube-lymph 
produced,  from  an  equal  number  of  punctures,  scarcely 
more  than  half  the  number  of  vesicles  resulting  from 
lymph  taken  direct  from  the  arm.*  Dr.  Pearse  has 
been  kind  enough  to  furnish  me  with  the  comparative 
results  of  696  vaccinations  performed  from  arm  to  arm 
in  the  year  1865,  at  the  Westminster  station  of  the 
National  Vaccine  Establishment,  and  55  vaccinations 
with  lymph  kept,  but  not  long  kept,  in  tubes.  The 
vaccination  was  performed  by  himself  in  every  case, 

act  of  storage  or  very  soon  after,  for  it  seems  quite  established 
(table,  p.  173)  that  lymph  stored  in  tubes  is  not  affecttd  by 
length  of  keeping.  Of  the  cases  in  that  table,  70  were  vac- 
cinated with  lymph  that  had  been  stored  less  than  a  week, 
with  as  much  relative  failure  as  where  the  lymph  was  kept 
three  months.  I  cannot  but  strongly  suspect  that  the  heat 
necessary  for  hermetically  sealing  does  exercise  an  injurious 
influence,  even  if  Dr.  Husband's  caution  to  fill  the  tube  only 
from  one-seventh  to  one-half  of  its  length  be  observed,  and  d 
fortiori  if,  as  is  sometimes  the  case,  the  tube  be  nearly  filled. 
*  Bousquet,  Nouveau  Traite  de  la  Vaccine,  p.  240.  It  is 
true  that  the  tubes  employed  by  MM.  Bousquet  and  Bourdin 
so  far  differed  from  Dr.  Husband's  that  they  were  slightly 
bulged  at  the  center,  but  I  cannot  regard  this  difference  as 
material,  and  the  results  these  observers  obtained  closely  cor- 
respond with  those  of  Dr.  Pearse,  who  used  Husband's  tubes. 
15* 


no 


HANDBOOK  OF   VACCINATION. 


and  by  six  punctures :  the  results,  reduced  to  percentage 
for  the  sake  of  comparison,  are  as  follows  : 


Kind  of 

Vaccination. 

Results  pek  100  Cases. 

Fail- 
ure. 

One 
ves. 

Two 
ves. 

Three 
vee. 

Four 
ves. 

Five 
ves. 

Six 
ves. 

Arm  to  arm.... 
Tubes 

0-72 
5-45 

0-43 

12-78 

105 
9-1 

1-87 
7-25 

3-3 
14-5 

5-0 
14-5 

87-6 
36-3 

These  results  represent  not  unfavorably,  so  far  as 
my^  own  observations  and  inquiries  (and  they  have 
been  very  considerable)  have  extended,  the  results  of 
tube-vaccination ;  as  regards  the  proportion  of  total 
failures,  they  are  fewer  than  Dr.  Husband's  own ;  as 
regards  the  number  of  vesicles  raised,  they  correspond 
very  closely  with  the  results  met  with  by  MM.  Bous- 
quet  and  Bourdin.  In  the  hands  of  many  good  vac- 
cinators, tubes  have  certainly  given  a  larger  amount 
of  failure  than  they  present;  but  even  these  results 
show  the  vast  difference  between  the  two  modes  of 
proceeding. 

It  is  not,  however,  with  arm-to-arm  vaccination,  but 
with  other  modes  of  preserving  lymph,  that  the  com- 
parison ought  to  be  made.  And  if,  in  making  this,  I 
were  to  take  into  account  only  what  really  skillful  vac- 
cinators can  do,  I  should  have  little  hesitation  in  saying 
that  vaccination  with  lymph  that  has  been  preserved 
by  drying,  if  only  it  be  used  within  a  few  days  or  a 
week  or  two  of  taking,  and  be  carefully  put  on  by 
abrasion,  is  more  successful  than  lymph  in  tubes. 
From  an  account  supplied  by  the  late  Mr.  Vincent,  of 


STORAGE  OF  LYMPH.  HI 

Oxford,  an  able  and  painstaking  vaccinator,  it  appears 
that  with  lymph  kept  dry,  but  used  within  periods 
rarely  exceeding  three  weeks  from  the  time  of  taking 
it,  and  inserted  by  abrasion,  he  had  only  three  per  cent, 
of  failures,  and  in  80  per  cent,  of  his  cases  produced 
vesicles  corresponding  to  the  number  of  insertions ; 
that  for  340  insertions  made  in  100  cases,  he  produced 
altogether  311  vesicles,  or  upwards  of  90  per  cent,  of 
insertional  success — no  single  case  having  less  than 
two  vesicles.*  These  results,  no  doubt,  are  indicative 
of  great  care  both  in  the  storage  of  the  lymph  and  in 
its  use,  but  I  have  met  with  few  really  skilled  vaccin- 
ators whose  failures  with  well-coated  points,  used 
within  the  periods  stated  by  Mr.  Vincent,  amounted 
to  more  than  five  per  cent.,  or  half  the  proportion  al- 
lowed by  Dr.  Husband  for  failure  with  tubes,  or  who 
did  not  get  a  much  larger  proportion  of  vesicles  than 
shown  in  the  tube-returns  of  Bousquet  and  Dr.  Pearse.f 
On  the  other  hand,  practitioners  who  are  not  expert  in 
the  use  of  dry  lymph  fail  with  it  so  frequently  that 
tubes  have  been  to  them  a  very  welcome  substitute. 
The  difficulties  attaching  to  tube-lymph  attach  exclu- 
sively to  the  collecting  and  storing,  not  to  the  use  of 
it :  the  difficulties  attaching  to  dry  lymph  attach  chiefly 
to  the  using  it.     But  if  vaccinators  were  all  properly 

♦Fifth  Annual  Keport  of  Medical  Officer  of  the  Privy 
Council,  p.  103. 

f  Marson's  experience,  he  tells  me,  is  very  decidedly  in 
favor  of  points  well  charged  (and  he  is  not  likely  to  use  any 
other),  even  though  they  should  have  been  kept  much  longer 
than  the  times  mentioned  above,  as  compared  with  tubes. 
Especially,  the  latter  disappoint  him  with  regard  to  the  num- 
ber of  resulting  vesicles. 


172  HANDBOOK  OF   VACCINATION. 

instructed,  I  believe  the  greatest  amount  of  success 
with  stored  lymph  would  be  found  to  attend  those 
modes  of  storage  where  no  heat  was  employed,  pro- 
vided the  points  or  glasses  were  well  charged,  and  the 
lymph  inserted  by  abrasion  within  a  week  or  two  of 
its  being  taken. 

But  for  long  storage — for  preserving  lymph  that 
must  be  kept  for  some  time  before  it  can  be  used,  as, 
for  example,  for  lymph  which  has  to  be  sent  abroad — 
the  balance  of  advantages  seems  to  me  altogether  in 
favor  of  tubes.  It  is  quite  true  that  lymph  dried  on 
points  or  glasses  has  been  used  with  the  most  complete 
success  after  keeping  three,  four,  six,  .nine  months  or 
more,  and  that  it  is  seldom  requisite,  even  with  lymph 
sent  abroad,  to  keep  it  so  long  before  it  can  be  employed. 
But  great  uncertainty  attaches  to  the  use  of  long-kept 
dry  lymph,  and  frequent  disappointment  attends  it, 
while  to  the  length  of  time  lymph  may  be  kept  in 
tubes  there  seems  practically  no  limit.  Mr,  Vincent 
found  that,  in  eleven  operations  with  dry  lymph  kept 
from  eight  to  fifteen  weeks,  two  failed,  and  thirty -four 
insertions  produced  but  twenty-three  vesicles  ;  that,  in 
nine  operations  with  dry  lymph  kept  from  fifteen  to 
twenty  weeks,  three  failed,  and  twenty-five  insertions 
produced  fifteen  vesicles.  Three  operations  with  lymph, 
kept  eleven  months,  succeeded  in  raising  a  single  vesi- 
cle in  one  case  only;  and  one  vaccination  with  lymph, 
kept  eighteen  months,  failed.  So  that  non-success  was 
much  in  proportion  to  the  length  of  storage.  On  the 
other  hand,  it  appears  to  me  well  made  out  that  length 
of  keeping  does  not,  in  the  least,  damage  lymph  stored 
in  tubes.  Some  years  ago  the  late  Professor  Alison, 
of  Edinburgh,  was  so  kind  as  to  furnish  me  with  the 


STORAGE  OF  LYMPH. 


m 


following  results  obtained  from  Dr.  Husband,  of  com- 
parative experiments  made  in  341  cases,  with  lymph 
kept  for  different  periods,  varying  from  a  day  to  two 
and  a  half  years  ;  the  greater  part  of  the  lymph  having, 
also,  for  experiment's  sake,  been  exposed  for  several 
hours  daily  to  a  temperature  of  from  80°  to  90°  Fahr. 


Length  of  time  the  lymph 
was  kept. 

No.  of  cases 

experimented 

on. 

Number  of 
these  CHses 
that  were 
successful. 

Number  of 
these  cases 
that  failed. 

Under  1  month 

126 

122 

93 

107 

107 

86 

19 

15 

7 

From  6—30  months*... 

Total 

341 

300 

41 

Mr.  Ceely,  who  was  requested  by  the  Medical  De- 
partment of  the  Privy  Council  to  make  inquiry  at 
Edinburgh,  in  1859,  as  to  the  results  of  this  mode  of 
preserving  lymph,  states  that  he  witnessed  the  suc- 
cessful results  of  vaccinations  from  tubes  that  had  been 
kept  5£,  6£,  *l\  years.f  And  lymph  which  has  been 
kept  in  this  way  for  longer  than  the  longest  of  these 
periods  has  been  used  with  perfect  success. 

When  the  transmission  of  lymph  abroad  is  to  trop- 


*  Dr.  Hushand  states  that  particular  circumstances,  not 
necessary  to  enter  into,  would  explain  satisfactorily  why  in 
these  experiments  the  older  lymph  was  apparently  more  active 
than  the  more  recent. 

f  Second  Ann.  Rep.  Medical  Officer  of  Privy  Council,  p  24. 


H4  HANDBOOK  OF   VACCINATION. 

ical  climates,  there  is  another  point  to  be  taken  into 
consideration  in  balancing  the  advantages  of  dry  lymph 
and  tube-lymph.  The  two  conditions  which  most  in- 
terfere with  the  successful  preservation  of  lymph  in 
hot  climates  are  heat  and  moisture.  When  lymph  sent 
out  on  points  to  tropical  countries,  by  the  National 
Vaccine  Establishment,  traveled  in  the  ordinary  mail- 
bags,  which  were  deposited  in  the  hot  and  unventilated 
holds  of  the  ships,  the  result  was,  as  Mr.  Tomkins, 
the  experienced  inspector  of  the  Establishment,  informs 
me,  that  it  very  frequently  spoilt.  It  is  now  the  cus- 
tom that  the  points  should  be  carried  in  the  writing- 
desk  of  some  officer  of  the  ship,  and  they  thus  arrive 
in  a  state  fit  for  use.  Tube-lymph  has  nothing  to  fear, 
at  all  events,  from  moisture ;  by  heat,  tropical  heat,  it 
may  be  affected,  and  Mr.  Tomkins  tells  me  it  certainly 
is.  He  ^says,  also  (and  any  statement  of  his  on  this 
point  is  worthy  of  the  utmost  attention),  that  the  expe- 
rience of  the  Establishment  is  still  in  favor  of  well- 
charged  points  as  the  best  mode  of  sending  lymph 
abroad,  to  whatever  climate.  It  is  certain,  however, 
that  lymph  sent  in  tubes  to  practitioners  in  various 
tropical  countries — the  East  and  West  Indies,  China, 
and  the  interior  of  Africa — has  succeeded  where  former 
transmissions  on  points  or  glasses  had,  possibly  from 
the  circumstances  pointed  out  by  Mr.  Tomkins,  failed. 
66.  Use  of  the  Vaccine  Crusts. — A  mode  of  storing 
lymph,  of  which  I  have  not  hitherto  spoken,  consists 
in  preserving  the  crusts  or  scabs  which  detach  them- 
selves from  genuine  vaccine  vesicles  at  the  termination 
of  the  vaccine  affection.  The  perfect  scab — the  ma- 
hogany-colored semi-transparent  scab  of  a  vesicle  which 
has  not  been  damaged,  either  for  taking  lymph  or  in 


STORAGE  OF  LYMPH.  IT 5 

any  other  way — should  alone  be  employed.  It  is  used 
by  moistening  it  with  water  on  the  back  of  a  plate,  and 
then  working  it  up  with  a  little  water  by  means  of  a 
clean  knife,  so  as  to  get  a  ropy  solution,  abundance  of 
which  should  be  inserted  (p.  132).  It  seems  at  first 
sight  strange  that  this  mode  should  succeed,  when  we 
know  that  the  lymph  taken  at  a  late  period  from  a 
vesicle  is  of  very  little  value.  Jenner  illustrates  and 
explains  the  difference  thus:  "Several  punctures  were 
made  in  the  arms  of  a  healthy  child  with  vaccine  mat- 
ter taken  from  the  edges  of  a  vesicle  when  three-quar- 
ters of  the  center  were  incrusted.  Not  one  of  them 
took  effect.  Some  weeks  afterward,  with  a  solution  of 
the  same  scab,  I  vaccinated  effectually.  This,  I  think, 
may  be  accounted  for — the  scab  is  made  up  of  the 
early  as  well  as  the  late-formed  matter."*  Still,  vac- 
cination from  the  scab  is  a  very  uncertain  mode  of  pro- 
ceeding, and  no  one  would  think  of  employing  it  now 
in  this  country,  where  so  much  better  means  are  at 
hand.  The  scab  has  at  times,  however,  been  found 
very  useful  as  a  means  of  transmitting  lymph  to  hot 
climates — crusts  so  sent  having  on  various  occasions 
succeeded  where  points  and  glasses  had  failed;  in  parts 
of  India  this  mode  of  storage  and  transmission  would 
appear  to  be  still  employed  to  a  considerable  extent, 
and  in  some  places  by  preference.  From  the  Hill 
Station  established  by  Dr.  Pearson  in  Gurwahl,  7794 
crusts  were  distributed  in  one  year — the  charges  sent 
out  on  points  and  glasses  being  only  1759.  But  one 
chief  reason  of  this  is  apparently  to  guard  against  the 
frauds  of  the  natives,  who  are  necessarily  much  em- 

*  Baron's  Life  of  Jcnncr,  vol.  ii.  j>.  401. 


1?6  HANDBOOK  OF   VACCINATION. 

ployed  for  the  verification  of  the  results  of  the  vaccina- 
tions performed  and  for  the  collection  of  lymph,  and 
who,  while  they  might  deceive  in  any  other  way,  can- 
not manufacture  vaccine  crusts.* 

67.  Early  Attempts  to  Convey  Vaccination  Abroad. 
— Some  of  the  early  attempts  to  convey  vaccination  to 
tropical  and  distant  countries  are  full  of  interest.  After 
various  endeavors,  successively  made,  to  send  lymph 
dry  to  India  had  failed,  Jenner  urged  that  more  effect- 
ual means  should  be  taken,  and  engaged  that,  if  twenty 
recruits  who  had  not  had  small-pox  were  selected,  and 
he  were  allowed  to  appoint  a  surgeon  to  attend  them, 
the  disease  should  be  conveyed  in  the  most  perfect 
state  to  any  of  our  settlements.  The  proposition  was 
too  startling  to  the  official  mind  of  that  day  for  it  to  be 
accepted,  and  the  honor  of  establishing  vaccination  in 
India  was  reserved  for  foreigners.  It  was  the  inde- 
fatigable Dr.  De  Carro,  of  Vienna,  who  succeeded  in 
this  way.  Taking  a  pair  of  glasses,  such  as  have  been 
described  (§  63),  one  of  which  had  a  concavity  on  its 
surface,  he  carefully  filled  the  cavity  with  charpie  satu- 
rated with  lymph;  a  drop  of  oil  was  then  put  on  the 
internal  surface  of  the  glasses,  and  the  flat  glass  was 
made  to  slide  upon  the  charpie  so  as  to  exclude  the  air 
as  much  as  possible ;  the  two  bits  were  then  tied  to- 
gether and  the  edges  sealed.  In  order  still  more  surely 
to  exclude  the  air,  Dr.  De  Carro  then  took  the  glasses 
to  a  wax-chandler's  and  there  dipped  them  again  and 
again  till  a  solid  ball  of  wax  was  formed  round  them, 
and  this  he  inclosed  in  a  box  filled  with  shreds  of 
paper.     In  this  state  the  packet  was  safely  conveyed 

*  Special  Keport  of  Bengal  Sanitary  Commission,  1864. 


STORAGE   OF  LYMPH.  Iff 

across  European  and  Asiatic  Turkey,  and  over  the 
whole  line  of  deserts  to  Bagdad.  When  it  arrived 
there  it  was  opened;  its  contents  were  still  liquid,  and 
succeeded  on  the  first  trial.  A  vaccinated  child  was 
then  sent  down  to  Bussorah,  and  from  its  arm  various 
vaccinations  were  there  successfully  performed.  The 
lymph  thus  raised  was  continued  in  weekly  succession, 
and  toward  the  end  of  May,  1802,  a  few  weeks  after  the 
stock  had  first  arrived  at  Bagdad,  some  of  it  was  sent 
on  by  the  "  Recovery"  to  Bombay.*  The  voyage  to 
Bombay  lasted  three  weeks.  With  the  lymph  thus 
conveyed,  from  twenty  to  thirty  subjects  were  vaccin- 
ated, but  only  one  of  them  successfully.  The  anxiety 
with  which  the  progress  of  this  case  was  watched  may 
be  easily  imagined.  On  the  eighth  day  five  .children 
were  vaccinated  from  it,  all  successfully,  and  hence 
commenced  the  diffusion  of  vaccination  over  India. 
The  lymph  thus  sent  was  not  from  Jenner's  stock,  but 
was  Milanese  lymph,  with  which  De  Carro  had  been 
furnished  by  Sacco.  And  it  was  lymph,  not  of  vaccine 
but  of  equine  origin,  which,  according  to  De  Carro,  had 
never  passed  through  the  cow.j" 

The  year  before  (in  1801),  Jenner  had  succeeded  in 
getting   lymph  out  to   Barbadoes   through  the   kind 

*  The  lymph  being  probably  transferred  from  subject  to 
subject  on  the  voyage,  but  this  I  cannot  quite  ascertain. 
Baron's  account  (Life  of  Jenner,  vol.  i.  p.  420,  seq.),  in  many 
respects  very  imperfect,  is  silent  about  this  ;  and  I  have  not 
been  able  to  refer  to  Dr.  Keir's  "Account  of  the  Introduction 
of  Cow-pox  in  India,"  a  book  which,  De  Carro  says,  is  little 
known,  but  contains  an  exact  statement  of  the  circumstance*. 

f  See  De  Carro's  Letter  to  Dr.  Monro,  London  Med.  Gaz., 
vol.  xxix.  p.  385. 

16 


178  HANDBOOK  OF   VACCINATION. 

offices  of  a  gentleman  who  vaccinated  several  sailors 
successively  on  the  voyage  *  And  the  year  after  (in 
1803),  the  Spanish  government  sent  an  expedition  from 
Corunna  for  the  purpose  of  conveying  vaccination  to 
all  the  Spanish  colonies,  and  to  the  foreign  possessions 
of  several  other  nations,  with  twenty-two  children  on 
board,  selected  for  the  preservation  of  the  vaccine  fluid 
by  transmitting  it  from  one  to  the  other  during  the  voy- 
age. The  Canary  Islands  and  the  American  possessions 
were  first  visited ;  and  the  disease  having  been  estab- 
lished in  America,  was  conveyed  on  to  the  possessions 
in  Asia,  twenty-six  more  children  being  taken  on  board 
at  Acapulco  in  New  Spain.  This  expedition  was  the 
means  of  conveying  cow-pox  to  some  of  the  Portuguese 
settlements  in  the  East,  and  to  the  great  empire  of 
China;  and,  on  the  way  home,  Dr.  Balmis,  who  in 
the  execution  of  his  mission  had  circumnavigated  the 
globe,  touched  at  St.  Helena,  and  (in  1806),  "strange 
to  say,  was  the  first  to  induce  the  English  inhabitants 
of  that  settlement  to  adopt  the  antidote,  "f  The  Bra- 
zilian government  in  like  manner  secured  its  introduc- 
tion (in  1803  or  1804),  by  sending  a  number  of  boys 
over  to  Lisbon,  who  were  vaccinated  in  succession  on 
the  home  voyage.  J 

*  Baron's  Life  of  Jeuner,  vol.  i.  p.  533. 
f  Ibid.,  vol.  i.  p.  606,  and  vol.  ii.  p.  78. 
%  Ibid.,  vol.  ii.  p.  10. 


OF  SKILL  IN   VACCINATING.  H9 


CHAPTER    IX. 

OF   SKILL   AND    SUCCESS   IN    VACCINATING,  AND   OP 
INSUSCEPTIBILITY  TO    VACCINATION. 

68.  What  is  successful  Vaccination?  Necessity 
for  a  Standard  of  Comparison. — Before  a  student  of 
vaccination  can  know  whether  he  ought  to  consider 
himself  a  successful  vaccinator  or  not,  he  must  have 
before  him  a  standard  of  comparison.  We  meet  daily 
with  practitioners  who  call  themselves  "successful" 
vaccinators,  but  who  evidently,  in  thus  speaking,  mean 
very  different  things;  for  while  one  would  think  it 
anything  but  successful  vaccination  to  fail  once  in 
every  hundred  operations,  another  will  interpret  this 
term  to  admit  of  two  or  three  per  cent,  of  failures, 
another  of  five  per  cent.,  another  even  of  ten  per  cent. 
A  failure,  indeed,  of  one  case  only  out  of  ten  is  very 
commonly  spoken  of  as  being  good  vaccination ;  and 
there  are  not  a  few  practitioners  who  think  they  do 
well  if  they  succeed  in  four  cases  out  of  five.*  There 
are,  besides,  degrees  of  success   in   vaccinating.     If 

*  To  an  active  and  long-established  vaccinator  in  London, 
who  did  his  vaccinations  chiefly  by  carrying  glasses  always 
about  in  his  pockets,  1  said,  "  Do  you  find  that  children  take 
that  way  as  well  as  if  you  got  them  together,  and  did  them 
from  the  arm  ?"  "I'll  engage  to  make  them  take  quite  as 
well  as  you  will  from  the  arm."  "But  how  many  miss?" 
"  Not  more  than  one  in  five." 


180  HANDBOOK  OF   VACCINATION. 

scarification  or  puncture  be  made  on  half  a  dozen  sepa- 
rate spots,  and  a  vesicle  arise  on  one  spot  only — a  sin- 
gle but  genuine  vaccine  vesicle — this  is  no  doubt,  in 
one  sense,  successful  vaccination ;  the  system  is  in- 
fected, and  it  will  be  impossible  at  the  moment  to  in- 
fect it  any  further;  but,  still,  the  result  is  so  far  un- 
successful, and  so  far  unsatisfactory,  that  it  is  much 
short  of  that  which  was  aimed  at,  and  of  that  which 
was  necessary  for  fully  accomplishing  the  object  of 
vaccination,  viz.,  for  protecting  the  patient  as  completely 
as  possible  against  small-pox.  Here,  again,  we  recog- 
nize the  want  of  a  standard  of  comparison.  While 
one  practitioner  is  disappointed  if  one  case  out  of  ten 
exhibits  a  number  of  vesicles  short  of  the  number  of 
insertions  of  lymph  which  had  been  made,  another  is 
very  well  content  if  he  get  the  full  number  of  vesicles 
in  only  half  his  cases. 

69.  Marson's  Standard. — Some  years  ago,  Marson 
gave  it  as  the  result  of  his  experience,  that  "  with  good 
lymph,  and  the  observance  of  all  proper  precautions, 
an  expert  vaccinator  should  not  fail  of  success  in  his 
attempts  to  vaccinate  above  once  in  150  times."* 
Marson's  own  habitual  rate  of  success  is,  indeed,  con- 
siderably greater  ;f    but  this    was  the  conclusion  to 

*  Medico-Chirurgical  Transactions,  vol.  xxxvi. 

f  Of  1479  vaccinations  performed  by  him  at  the  Blackfriars' 
station  of  the  National  Vaccine  Establishment,  in  1863,  the 
operation  failed  at  the  first  attempt  in  three  cases  only ;  and 
on  a  recent  visit  to  this  station  I  found  that,  of  the  last  thou- 
sand operations  in  which  the  results  had  been  inspected,  there 
had  been  only  one  failure.  At  the  Birmingham  station  of  the 
Establishment,  in  1864,  out  of  considerably  more  than  a  thou- 
sand inspected  cases,  there  were  three  failures ;  in   1865,  out 


OF  SKILL  IN   VACCINATING.  181 

which  his  experience  had  led  him  as  to  what  might  be 
reasonably  expected  of  vaccinators.  And  that  this  is 
not  at  all  too  high  a  standard  is  manifest  from  the  re- 
sults which,  on  examination  of  the  records  kept  at 
some  of  the  stations  of  the  National  Vaccine  Estab- 
lishment, I  find  to  have  attended  their  practice.  The 
failures  were,  on  the  average  of  a  large  number  of 
cases,  spread  over  a  considerable  time,  but  one  in  170 
operations.  We  may  fairly,  therefore,  adopt  Marson's 
rate  as  the  standard  below  which  no  vaccinator,  vac- 
cinating from  arm  to  arm,  has  any  right  to  be  satisfied 
with  his  performances.  With  regard  to  the  degree  of 
success,  it  appeared  from  the  records  of  the  stations 
above  referred  to,  that,  in  their  practice,  vesicles  had 
risen  at  every  point  of  insertion  of  lymph,  in  consider- 
ably more  than  ninety  per  cent,  of  the  children  oper- 
ated on,  while  the  proportion  of  cases  in  which  a  sin- 
gle vesicle  only  had  resulted  from  the  four,  five,  or  more 
insertions  made,  was  about  one  in  a  hundred. 

70.  A  Standard  when  Stored  Lymph  is  used. — 
But  the  operation  in  all  these  cases  was  done  under 
the  circumstances  most  favorable  for  success — with  se- 

of  1068  inspected  cases,  there  was  no  failure  ;  and  on  a  recent 
visit,  I  found  that  out  of  the  last  thousand  inspected  cases, 
three  only  had  failed.  Mr.  Sheppard,  who  has  charge  of  the 
Bristol  station  of  the  Establishment,  performed  and  inspected 
some  years  ago,  when  the  cases  there  were  far  more  numerous 
than  at  present  (the  absurd  division  of  public  vaccination  now 
existing  in  that  city  not  having  then  been  adopted),  abovo 
2000  vaccinations  without  missing  on  one  occasion  ;  and  Mar- 
son  tells  me  the  same  thing  happened  to  him  once  at  the 
Small-pox  Hospital,  at  the  time  when  the  vaccinations  at  that 
institution  (before  the  introduction  of  the  present  miblic  sys- 
tem) amounted  to  some  thousands  a  year. 
10* 


182  HANDBOOK  OF   VACCINATION. 

lected  lymph,  inserted  direct  from  arm  to  arm.  When 
the  operation  has  to  be  done  with  stored  lymph,  the 
same  amount  of  success  cannot  be  looked  for  (§  53), 
and  so  many  circumstances  affect  the  successful  use  of 
stored  lymph  (particularly,  when  the  lymph  is  dry- 
stored,  the  length  of  time  it  has  been  kept)  that  it  is 
much  more  difficult  to  fix  a  standard.  But  if  a  practi- 
tioner be  careful  to  use  his  points  or  glasses  within  a 
week  or  ten  days  of  the  lymph  being  taken  (and  it  is 
presumed  that,  in  this  country,  lymph  need  never  be 
older,  and  scarcely  ever  so  old  as  this,  before  it  can  be 
employed),  and  to  put  the  lymph  well  on  by  abrasion, 
he  certainly  ought  not  to  fail  in  more  than  five  per 
cent,  of  his  operations,  or  to  obtain  in  less  than  three- 
quarters  of  his  cases  the  full  results  he  aimed  at.* 

71.  Skill  of  the  Individual  Vaccinator  the  most 
important  of  all  the  conditions  for  success.  Neces- 
sity for  special  Instruction. — But  whether  the  vac- 
cination be  done  from  arm  to  arm,  or  whether  it  be 
done  otherwise;  whether  it  be  performed  under  the 
circumstances  most  favorable,  or  under  circumstances 
less  conducive  to  success,  surely  the  first  of  all  things 
necessary  for  its  being  well  done  is  that  those  who 
have  to  perform  it  shall  have  been  duly  instructed  in 
their  work,  and  shall  be  possessed  of  a  competent 
knowledge  of  that  which  they  have  to  do.  Jenner 
always  strongly  insisted — and  it  was  a  point  equally 
dwelt  upon  by  all  who  obtained  early  distinction  as 
vaccinators,  as  Ring,  Dunning,  Bryce,  etc. — that  no 
one  ought  ever  to  take  upon  himself  to  perform  vac- 

*  Mr.  Vincent's  successes  were  greater  than  these,  and  the 
lymph  he  used  was  in  some  of  the  cases  three  weeks  old. 


OF  SKILL  IN   VACCINATING.  183 

cination  who  had  not  been  specially  instructed  in  it. 
"Although,"  says  Jenner,  "vaccine  inoculation  does 
not  inflict  a  severe  disease,  but,  on  the  contrary,  pro- 
duces a  mild  affection  scarcely  meriting  the  term  dis- 
ease, yet,  nevertheless,  the  inoculator  should  be  ex- 
tremely careful  to  obtain  a  just  and  clear  conception 

of  this  important  branch  of  medical  science A 

general  knowledge  of  the  subject  is  not  sufficient  to 
enable  or  to  warrant  a  person  to  practice  vaccine  inoc- 
ulation ;  he  should  possess  a  particular  knowledge, 
and  that  which  I  would  wish  strongly  to  inculcate,  as 
the  great  foundation  of  the  whole,  is  an  intimate  ac- 
quaintance with  the  character  of  the  true  and  genuine 
vaccine  pustule  "*  And  again :  "  I  expect  that  cases  of 
this  sort  (failures  of  so-called  vaccination  to  protect 
against  small-pox)  will  flow  in  upon  me  in  no  incon- 
siderable numbers;  and  for  this  plain  reason:  a  great 
number,  perhaps  the  majority  of  those  who  inoculate, 
are  not  sufficiently  acquainted  with  the  nature  of  the 
disease  to  enable  them  to  discriminate  with  due  ac- 
curacy between  the  perfect  and  imperfect  pustule. 
This  is  a  lesson  not  very  difficult  to  learn,  but  unless 
it  is  learnt,  to  inoculate  the  cow-pox  is  folly  and  pre- 
sumption, "f  And  the  Royal  College  of  Physicians  of 
London,  in  their  memorable  Report  on  Vaccination  in 

*  Varieties  and  Modifications  of  the  Vaccine  Pustule,  p.  13. 

f  Jenner  in  Letter  to  Lord  Berkeley,  Baron's  Life  of  Jen- 
ner, vol.  ii.  p.  13.  In  various  parts  of  his  correspondence, 
Jenner  refers  to  mischief  of  different  kinds  that  had  arisen 
from  want  of  proper  knowledge  of  the  subject  on  the  part  of 
vaccinators.  In  one  letter  (Baron's  Life,  vol.  ii.  p.  373)  he 
tells  Moore,  the  Director  of  the  National  Vaccine  Establish- 
ment, that  he  ought  to  open  a  vaccine  school. 


184  HANDBOOK  OF   VACCINATION. 

180*7,  remark  that  "those  who  perform  vaccination 
ought  to  be  well  instructed,  and  should  have  watched 
with  the  greatest  care  the  regular  progress  of  the  pus- 
tule, and  learnt  the  most  proper  time  for  taking  the 
matter."*  With  such  injunctions,  proceeding  from 
such  authorities,  it  seems  strange  that  a  thorough  ac- 
quaintance with  vaccination  should  never  have  been 
required  by  any  of  the  colleges  and  corporations  who 
are  authorized  to  license  for  medical  practice  in  this 
country,  as  one  of  the  conditions  for  receiving  their 
license,  and  that  at  this  very  day  there  is  not  any  test 
of  medical  proficiency  in  England  which  implies  a 
competent  knowledge  of  vaccination.  Till  within  the 
last  few  years,  students  who  were  candidates  for  the 
license — whether  of  the  College  of  Surgeons  or  of  any 
other  of  the  licensing  boards — were  not  called  on  to 
produce  evidence  of  having  received  any  instruction 
whatever  in  vaccination.  Accordingly,  students  have, 
within  my  own  knowledge,  been  admitted  to  practice, 
and  even  been  appointed  public  vaccinators,  who,  so 
far  from  having  learnt  the  niceties  connected  with  the 
proper  performance  of  vaccination,  had  never  even 
seen  the  operation  done.  And  although  regulations 
made  by  some  of  these  boards  within  the  last  few 
years  (and  since  public  attention  has  been  prominently 
called  to  their  omission)  now  require  that  each  student 
presenting  himself  for  examination  should  produce  the 
certificate  of  some  member  of  the  particular  licensing 
body,  or  of  some  "registered  medical  practitioner,"  as 
to  his  proficiency  in  vaccination,  a  certificate  that  can 

*  Papers  relating  to  the  History  and  Practice  of  Vaccina- 
tion, p.  8. 


OF  SKILL   IN    VACCINATING.  185 

be  thus  miscellaneously  obtained  conveys,  assuredly, 
no  guarantee  of  the  student's  real  competency.  For, 
apart  from  other  obvious  considerations,  it  must  mani- 
festly depend  on  whether  the  practitioner  giving  the 
certificate  were  a  good  or  a  bad  vaccinator,  whether 
his  instruction  and  certificate  of  competency  were  worth 
anything  or  not.  But  this  is,  so  far  as  I  am  aware, 
the  only  test  attempted.  Further,  it  was  not  till  1859 
that  any  authorized  places  for  the  practical  teaching  of 
vaccination  existed.  In  that  year,  the  Lords  of  the 
Council,  having  been  required  by  one  of  the  provisions 
of  the  Public  Health  Act,  1858,  to  take  security  "for 
the  due  qualification"  of  persons  to  be  thereafter  ap- 
pointed public  vaccinators,  certain  of  the  stations  of 
the  National  Vaccine  Establishment  were  selected  as 
places  for  instructing,  or  for  testing  by  practical  exam- 
ination, the  qualifications  of  all  candidates  for  the  office 
of  public  vaccinator,  and  of  any  other  professional  per- 
sons who  desired  to  possess  themselves  beforehand  of 
evidence  of  their  fitness  for  that  office.  These  stations, 
which  combine  the  two  essential  requisites  of  a  compe- 
tent teacher  and  a  sufficient  number  of  cases  for  instruc- 
tion, are  now  open  to  all  medical  students,  and  it  is 
greatly  to  be  desired  that  all  students,  whether  they 
are  likely  or  whether  they  are  not  likely  to  become 
public  vaccinators,  should  avail  themselves  of  the  op- 
portunities of  sound  praetical  instruction  in  vaccination 
which  they  afford.*     There  are  few  students,  what- 

*  The  National  Vaccine  Board — at  that  time  consisting  of 
the  Presidents  of  the  Colleges  of  Physicians  and  Surgeons, 
the  Senior  Censor  of  the  College  of  Physicians,  and  the  Medi- 
cal Officer  of  the  Privy  Council — had  hoped  and  anticipated 


186  HANDBOOK  OF   VACCINATION. 

ever  their  opportunities  of  seeing  vaccination  elsewhere 
may  have  been,  who  will  not  derive  advantage  from 
carefully  following,  for  some  weeks,  the  practice  of 
these  stations,  and  there  working  under  instruction, — 
for  it  is  only  by  practically  working  that  the  discrim- 
ination and  dexterity  necessary  to  make  a  good  vac- 
cinator can  properly  be  acquired. 

72.  Advantages  which  would  attend  the  appoint- 
ment of  Professed  "Vaccinators." — "  The  advantages 
which  would  result  from  confining  the  practice  of  vac- 
cination to  such  persons  only,  even  among  those  of  the 
medical  profession,  as  are  duly  qualified  to  undertake 
it,"  along  with  other  considerations,  induced  one  of  the 
most  distinguished  of  the  early  vaccinators,  Mr.  Bryce, 
to  propose  that  vaccination  of  rich  and  poor  alike  should 
be  carried  on  entirely  by  a  special  class  of  medical  prac- 
titioners, not  otherwise  occupied  in  medical  practice, — 
by  "  vaccinators"  to  be  appointed  for  the  purpose.*  The 
benefits  which  would  have  resulted  to  the  public,  had 
such  a  course  been  adopted,  are  in  my  opinion  incal- 
culable ;  nor  must  I  withhold  the  expression  of  the 
strong  conviction,  to  which  my  experience  has  led  me, 
that  the  best  of  all  things  that  could  be  done  to  protect 
the  population  well  against  small-pox  would  be  to 
adopt  this  course  now.  At  all  events,  it  is  indispensa- 
ble that  all  who  vaccinate  should  be  trained  to  the  work. 
In  the  inquiry,  already  referred  to,  which  was  made 

that  attendance  at  the  stations  appointed  by  them  would  have 
been  required  by  the  Medical  Licensing  Boards  of  all  candi- 
dates for  their  respective  licenses.  But  this  hope  has  not 
hitherto  been  realized. 

*  Practical  Observations  on  the  Inoculation  of  Cow-pox,  2d 
Edition,  Appendix,  p.  5. 


OF  SKILL  IN   VACCINATING.  187 

by  myself  and  Dr.  Buchanan  into  the  state  of  vaccin- 
ation in  London  in  1863,  we  compared  the  results  ob- 
tained by  various  vaccinators,  as  shown  by  the  cica- 
trices on  the  arms  of  large  numbers  of  children,  and 
could  not  but  express  ourselves  as  "  struck  with  the 
great  difference  of  results  of  diiferent  operators,  work- 
ing under  apparently  the  same  conditions.  This  differ- 
ence," we  stated,  "was  quite  irrespective  of  general 
professional  attainments,  and  depended  altogether  on 
special  knowledge  and  special  practical  skill ;  for, 
however  trifling  as  a  surgical  operation  vaccination  may 
be,  there  is  nothing  more  certain  than  this,  that  careful 
observation,  practical  experience,  and  painstaking  ac- 
curacy are  indispensable  for  securing  its  proper  results. 
We  do  not  hesitate  for  a  moment  to  express  our  strong 
conviction  that  the  vaccination  of  London  would  be 
best  done  by  a  few  thoroughly  trained  vaccinators  who 
devoted  themselves  exclusively  to  the  work."* 

73.  Consequences  that  have  resulted  from  want  of 
proper  Instruction  and  of  an  Authorized  System  of 
Vaccination,  (a)  Marson's  Statements. — Nearly  fif- 
teen years  ago  (1853),  Mr.  Marson  called  the  attention 
of  the  profession,  in  a  paper  read  to  the  Medico-Chir- 
urgical  Society  of  London, f  to  the  large  amount  of  un- 
skillful vaccination  that  was  to  be  met  with  in  England, 
and  to  its  consequences  as  shown  in  the  experience  of 
the  Small-pox  Hospital.  Persons  were  found  to  pre- 
sent themselves  frequently  with  small-pox  at  the  hos- 
pital who  stated  that  they  had  been  cut  five,  six,  or 
eight  times  or  more  for  cow-pox  without  effect ;  "  an 

*  Sixth  Keport  of  Medical  Officer  of  Privy  Council,  p.  118. 
f  Medico-Chirurgical  Transactions,  vol.  xxxvi. 


188  HANDBOOK  OF   VACCINATION. 

evil,"  he  said,  "which  could  happen  rarely  in  careful 
hands.  Such  persons,"  he  continues,  "think  it  of  no 
use  having  the  operation  tried  again,  that  it  will  not 
take  effect  if  they  do,  and  ultimately  they  are  attacked 
by  small-pox,  and  perhaps  die ;  whereas  had  they 
fallen  into  the  hands  of  a  good  vaccinator,  their  lives 
would  most  likely  have  been  saved."  A  large  propor- 
tion of  the  English  admitted  to  the  hospital,  in  whom 
the  vaccination  had  taken  effect,  were  shown  by  their 
cicatrices  to  have  been  very  imperfectly  done,  and  their 
small-pox  was  severe  and  often  fatal :  while  Swedes, 
and  Danes,  and  Norwegians,  and  Prussians,  of  whom 
many  had  been  brought  to  the  hospital  with  small-pox, 
had,  from  having  been  thoroughly  vaccinated,  the 
small-pox  in  its  light  varicelloid  form.  Three  years 
afterward  (in  1856),  he  again  referred,  in  a  petition  to 
the  House  of  Commons,  to  the  "  large  amount  of  very 
insufficient,  almost  useless,  vaccination  performed  in 
England,"  traceable  chiefly  to  no  authorized  system  of 
vaccination  having  been  established,  but  to  every  one 
having  vaccinated  in  the  manner  he  or  she  might  think 
proper.* 

(b)  Official  Inquiry. — These  allegations,  proceeding 
from  such  authority,  and  confirmed  as  they  were  by 
many  circumstances,  were  far  too  serious  to  be  over- 
looked ;  and  one  of  the  most  important  objects  of  the 
inquiry  which  the  Lords  of  the  Council,  in  1859,  directed 
to  be  made  by  the  Medical  Department  of  the  Privy 
Council  into  the  state  of  vaccination  in  England,  was 
to  ascertain  fully  how  far  this  unsatisfactory  per  for  m- 

*  Papers  relating  to  the  History  and  Practice  of  Vaccina- 
tion, p.  25. 


OF  SKILL  IN   VACCINATING.  189 

ance  of  vaccination  was  diffused  over  the  kingdom,  and 
to  trace  more  minutely  its  causes,  with  a  view  to  their 
remedy.  In  the  course  of  that  inquiry,  which,  under 
the  instructions  of  the  Medical  Officer,  was  made  by 
Drs.  Stevens,  Buchanan,  Sanderson,  and  myself,  per- 
sonal observations,  by  one  or  other  of  us,  were  extended 
to  every  vaccination  district  in  England.  The  facts  as- 
certained by  each  of  us,  respectively,  will  be  found  in 
the  reports  presented  to  Parliament.*  In  stating  gen- 
erally the  results  of  that  inquiry,  so  far  as  regards  the 
imperfect  performance  of  vaccination  in  England — re- 
sults which  entirely  bore  out  the  statements  of  Mr. 
Marson — it  will  be  most  convenient  to  trace  these  from 
their  causes  upward. 

In  the  first  place,  the  rule  which  was  laid  down  fifty 
years  ago  by  the  National  Vaccine  Establishment,  and 
has  never  been  departed  from  in  the  practice  of  the 
Establishment^  viz.,  thoroughly  to  infect  the  system  in 
vaccinating  by  making  at  least  four  punctures,  or  by 
production  (if  vaccination  were  not  done  by  puncture) 
of  equivalent  local  results,  as  carried  out  by  compara- 
tively few  only  of  the  public  vaccinators  of  the  king- 

*  See,  in  the  Annual  Reports  of  the  Medical  Officer  of  the 
Privy  Council,  iii.-vii.  inclusive,  the  Appendices  concerning 
"Local  Inquiries  as  to  Vaccination." 

f  The  National  Vaccine  Board,  in  their  Report  for  1820, 
state  that  the  principle  of  the  practice  they  adopt  and  incul- 
cate is  "  to  affect  the  constitution  of  each  individual  very 
completely  with  the  vaccine  disease  ;"  and,  adverting  to  their 
directions  to  their  own  operators  to  make  four  punctures,  they 
add,  "from  extensive  experience  and  numerous  reports  the 
Board  have  become  most  earnestly  desirous  that  more  rather 
than  fewer  vesicles  should  he  produced." 

17 


190  HANDBOOK  OF   VACCINATION. 

dom ;  secondly,  facts  of  the  utmost  practical  importance 
relative  to  vaccination,  which  had  been  brought  to  pro- 
fessional notice,  through  the  ordinary  channels  of  publi- 
cation, years  and  years  before — such  facts,  for  example, 
as  those  noted  by  Marson  with  regard  to  the  influence 
exercised  on  the  small-pox  death-rate  by  the  quality  of 
the  vaccination  performed  (§  92,  a) — were  found  to  be 
absolutely  unknown  to  a  large  majority  of  vaccinators; 
thirdly,  the  rules  about  the  proper  period  for  lymph- 
taking,  about  herpetic  and  other  eruptions  as  affecting 
the  course  of  the  vaccine  vesicle,  etc.,  were  extensively 
unknown  or  extensively  disregarded,  some  thinking  it 
a  matter  of  no  moment  whether  Jenner's  "golden  rule" 
were  observed  or  not,  and  others  taking  the  lymph  by 
'preference  at  the  very  periods  at  which  he  had  specially 
pointed  out  that  it  ought  not  to  be  taken  ;*  and  lastly, 
storage  of  lymph  and  the  use  of  stored  lymph  were  but 
very  imperfectly  understood.  There  was,  in  fact,  a  state 
of  things  which  could  never  have  existed,  had  only 
Jenner's  injunctions  been  regarded,  and  had  there  been 
proper  authorized  teaching  on  the  subject.f 

It  was  found  that,  partly  as  the  natural  consequences 
of  the  above  defects,  but  also  partly  because  of  the  im- 
perfect arrangements  about  lymph-supply,  on  which  I 
have  before  commented,  vaccination  was  carried  on,  in 
a  very  large  number  of  districts,  extending  all  over  the 
kingdom,  with  an  unwarrantable  amount  of  failure,  or 

*  Some  important  evidence  on  this  point  had  heen  commu- 
nicated to  the  Epidemiological  Society  in  1851-2. 

f  The  above  statements,  it  must  be  remembered,  represent 
things  as  existing  in  18G0-4.  The  inquiry  itself  produced  im- 
provement in  many  respects,  and  there  is,  on  the  whole,  a 
much  better  state  of  things  now  existing. 


OF  SKILL   IN   VACCINATING.  191 

with  the  production  of  results  which,  though  in  one 
sense  successful,  still  left  the  vaccinated  persons  but 
very  imperfectly  protected  against  small-pox.  It  was, 
indeed,  a  very  common  thing  that  children  should  have 
been  cut  two,  three,  or  four  times  before  they  took,  or 
without  even  taking  then.  Children  on  whom  such 
trials  had  been  made,  but  who  still  had  no  marks  of 
vaccination,  were  met  with  repeatedly  in  attendance  at 
public  schools  ;  frequently,  children  growing  into  man- 
hood or  womanhood  told  how  many  times  they  had 
been  done,  and  said  it  was  no  use  their  being  done  any 
more,  "  for  they  wouldn't  take.  "*  And  many  grown-up 
men  and  women,  under  similar  circumstances,  had  the 
same  belief.  Vaccinators,  generally,  had  a  very  low 
standard  of  success ;  and  while  some  thought,  as  has 
been  already  said,  that  for  four  operations  to  take  out 
of  five  was  a  satisfactory  result,  others  thought  two 
successful  cases  out  of  three  was  as  much  as  could  rea- 
sonably be  expected,  and  others  regarded  success  to  be 
very  much  a  matter  of  chance.  "  Sometimes  they'll  take, 
and  sometimes  they  won't,  you  can't  exactly  tell  which," 
were  the  words  of  the  vaccinator  of  a  large  metropoli- 

*  Many  children  are  brought  every  year  to  some  of  the  Es- 
tablishment stations  to  be  vaccinated  who  have  been  cut  three, 
four,  five  times,  sometimes  six  or  seven  times,  elsewhere,  with- 
out effect.  But  there  is  hardly  an  instance  (I  do  not  know  one) 
of  failure  to  infect  these  children  at  the  Establishment,  and 
almost  always  at  the  first  operation.  An  excellent  public  vac- 
cinator in  the  West  of  England,  on  his  first  appointment  to  a 
district  some  years  ago,  found  a  large  number  of  children  in 
the  district  whom  his  predecessor,  having  made  various  at- 
tempts to  vaccinate,  had  pronounced  "insusceptible;"  but 
there  was  not  one  of  them  whom  he  found  any  difficulty  in 
infecting. 


192  HANDBOOK  OF   VACCINATION. 

tan  district ;  and  they  describe,  not  unfairly,  the  exploits 
of  a  certain  class  of  vaccinators.  Failure  to  raise  a 
number  of  vesicles  corresponding  to  the  number  of 
lymph-insertions  was  still  more  common,*  and  in  a 


*  The  failures  were,  of  course,  by  far  the  most  frequent  with 
stored  and  conveyed  lymph,  but  even  in  vaccinating  from  arm 
to  arm  the  results  of  many  vaccinators  were  far  from  what 
they  should  be.  The  failures  with  dry  lymph  in  some  hands 
were  really  surprising.  One  vaccinator  had  in  one  year  46 
failures  out  of  155  vaccinations,  and  in  another  year  94  out  of 
171.  In  a  district  in  South  Wales,  I  found  great  complaints 
of  the  people  that  they  "got  such  a  bad  pock;"  which  did  not 
in  the  least  mean  that  their  children  had  suffered  any  ill 
consequences  from  vaccination,  but  that  they  had  to  have 
them  done  again  and  again  before  the  operation  would  suc- 
ceed. The  following  note  of  results  met  with  in  certain  dis- 
tricts in  Yorkshire  will  give  some  idea  of  the  failures  of  dry 
lymph  in  unskilled  hands.  Taking  eleven  districts  in  which 
the  vaccination  was  performed  almost  exclusively  with  dry 
lymph,  and  in  none  of  which  was  it  the  custom  to  insert  lymph 
in  less  than  two  places,  while  in  some  it  was  inserted  in  three, 
four,  or  more  places,  I  found  that  upwards  of  30  per  cent,  of 
the  children  examined  (446  out  of  1465)  had  but  one  mark. 
In  a  district  in  which  it  was  the  practice  to  make  six  inser- 
tions, only  74  out  of  147  children  had  more  than  two  marks; 
several  children  had  been  cut  again  and  again ;  and  one  four 
times.  In  my  notes  are  repeated  entries  of  this  kind:  "  Mr. 
P.  (vaccinator)  says  they  take  very  badly,  have  often  to  be 
done  two  or  three  times  over."  "Of  54  children  15  had  but 
one  mark,  three  had  been  tried  twice  without  effect,  and  one 
three  times."  "  Mr.  R.  (another  vaccinator)  says  he  has  often 
to  do  them  a  second  time  before  they  will  take,  and  sometimes 
three  or  four  times."  "  Mr.  W.  (another  vaccinator)  says 
they  take  very  badly;  the  number  of  vesicles  varies  much; 
he  always  inserts  six  points,  but  often  only  one  or  two  take," 
etc.  etc.      These  entries  have  not  reference  to  wild  country 


OF  SKILL  IN   VACCINATING.  193 

large  number  of  districts  the  imperfect  character  and 
quality  of  the  cicatrix  attested  the  inferior  quality  of 
the  lymph  that  had  been  used.*  In  striking  contrast, 
indeed,  with  such  results  as  the  foregoing  were  those 
met  with  in  a  large  number  of  districts  fortunately  pos- 
sessed of  vaccinators  who  had  been  well  trained  to  their 
work.  A  group  of  children,  of  various  ages,  and  vac- 
cinated at  various  times  by  one  vaccinator,  would  by 
their  scars  show  themselves,  with  rare  exceptions, 
thoroughly  protected  against  small-pox ;  while  in  an 
adjacent  district,  similarly  situated  in  all  other  respects, 
or  in  an  adjacent  school — probably  side  by  side  with 
the  former  children,  in  the  same  school  or  district — 
would  be  found  another  group,  whose  vaccination  had 
been  the  work  of  another  hand,  few  of  whom  were 
really  well  protected  against  small-pox,  and  in  many  of 
whom  the  vaccination  had  been  little  more  than  a  sham. 
The  difference  was  so  great  that  it  was  often  difficult 
to  persuade  a  vaccinator  of  the  latter  kind  that  such 
marks  as  he  looked  upon  with  surprise  were  but  the 

districts,  in  which  it  might  he  supposed  the  use  of  preserved 
lymph  was  a  necessity;  the  very  first  of  them,  for  example, 
was  the  statement  of  a  public  vaccinator  of  the  City  of  York. 
*  In  speaking  of  inferior  lymph  or  bad  lymph,  I  beg  that 
it  may  be  most  distinctly  understood  that  I  mean  lymph  of 
inferior  infective  power,  lymph  that  does  not  "take  well," 
and  therefore  leaves  the  persons  vaccinated  with  it  but  poorly 
protected  against  small-pox.  Of  bad  lymph  in  any  other  sense 
of  the  term,  of  lymph  that  has  conveyed  any  disease  or  done 
any  other  harm,  I  know  nothing.  I  have  never  met  with  a 
single  instance  of  mischief  arising  in  this  way,  nor  do  I  think 
has  any  one  of  my  colleagues.  I  have  investigated  several 
instances  where  there  was  allegation  of  it ;  but  in  no  one  of 
them  was  there  a  tittle  of  proof  or  even  of  probability. 
17* 


194  HANDBOOK  OF   VACCINATION. 

ordinary  results  of  good  vaccination.*  Taken  on  the 
whole,  imperfect  or  incomplete  vaccination  was  found 
to  have  so  far  prevailed  over  England  that,  on  examin- 
ation of  the  arms  of  nearly  half  a  million  of  vaccinated 
children,  it  was  found  that  about  one  in  eight  only  had 
been  so  vaccinated  as  to  have  the  fullest  protection 
against  small-pox  that  vaccination  is  capable  of  afford- 
ing ;  that  not  more  than  one  in  three  could  be  considered 
as  even  tolerably  well  protected ;  and  that  at  least  one 
in  four  had  been  so  imperfectly  done  as  to  run  no  incon- 
siderable risk  of,  at  some  time  or  other  in  their  lives,  con- 
tracting small-pox,  and  having  it  badly,  probably  even 
fatally,  f  In  fact,  in  the  words  employed  by  Dr.  Stevens 
in  one  of  his  reports,  "A  very  small  proportion  of  the 
supposed-to-be-vaccinated  population  had  received  such 
protection  from  death  by  small-pox  as  efficient  vaccina- 
tion is  known  to  give."! 

*  See  Fourth  Report  of  Medical  Officer  of  Privy  Council,  p. 
63  ;  and  Sixth  Eeport,  pp.  141-2. 

f  The  children  on  whom  these  observations  were  made  were 
generally  of  the  class  that  attends  public  schools.  Most  of  them 
had  been  vaccinated  by  public  vaccinators,  but  a  large  num- 
ber by  private  practitioners.  Without  affording  statistical 
evidence  of  the  fact,  a  strong  impression  was  left  that,  as  a 
rule,  the  latter  were  less  well  done  than  the  former.  Among 
the  upper  and  middle  classes  in  England,  I  know,  from  my 
own  opportunities  of  observation,  that  the  vaccination,  in 
many  instances,  has  been  very  imperfectly  done.  If  the  vac- 
cinated in  these  classes  do  not  contract  small-pox  so  frequently 
as  the  vaccinated  among  the  lower  orders,  it  is  not  because  of 
their  better  vaccination,  but  because  of  their  less  exposure  to 
the  infection. 

%  Fifth  Report  of  Medical  Officer  of  Privy  Council,  p.  66. 
The  imperfect  way  in  which,  frequently,  vaccination  had  been 


OF  SKILL  IN   VACCINATING.  195 

Thus  it  is  that  we  are  able  to  read  without  surprise 
that,  of  150  cases  of  small-pox  treated  in  the  practice 
of  the  Lincoln  General  Dispensary  during  a  recent  epi- 
demic of  the  disease,  no  fewer  than  18  were  in  persons 
who  said  they  had  been  vaccinated,  but  that  the  vac- 
cination had  not  taken  1*  In  20  years — -from  1836  to 
1855 — there  were  370  persons  admitted  to  the  Small- 
pox Hospital,  with  small-pox,  who  said  they  had  been 
vaccinated,  but  who  had  no  mark  of  it,  and  in  101  of 
them  the  disease  was  fatal.  In  the  same  20  years, 
there  were  more  than  4000  persons  admitted  with  small- 
pox who  had  a  mark  or  marks  of  vaccination,  and  298 
of  them  died  ;f  but  only  5  of  these  deaths  took  place 
among  that  portion  of  these  persons  (544  in  number) 
whose  marks  showed  them  to  have  been  vaccinated  in 
the  best  way.  Though  it  belongs  to  a  future  section 
(§  92,  a)  to  state  in  detail  the  important  facts  collected 
at  the  Small-pox  Hospital,  it  was  necessary  to  advert 
to  them  in  this  place,  because,  until  the  consequences 
that  may  result,  indeed  are  almost  sure  at  some  time 
or  other  to  result,  from  the  bad  and  unskillful  perform- 
ance of  vaccination  have  taken  thorough  possession  of 
the  professional  and  public  mind,  we  are  not  likely  to 
have  the  operation  done  so  well  as  it  ought  to  be.  "  If," 
says  Marson,  "a  little  operation — little  apparently  in 

performed,  was  noticed  also  by  many  of  the  Metropolitan 
Medical  Officers  of  Health  in  their  examination  of  school- 
children during  the  epidemic  of  small-pox  in  London  in 
1859-60  (Third  Keport  of  Medical  Officer  of  Privy  Council, 
p.  59). 

*  British  Medical  Journal,  Jan.  14,  1865. 

f  Article  M  Small-pox,"  in  System  of  Medicine,  edited  by  J. 
K.  Reynolds,  M.D.,  vol.  i.  p.  473. 


196  IIANDBOOK  OF   VACCINATION. 

practice,  but  very  important  in  its  results — well  per- 
formed, can  save  many  lives,  as  most  certainly  it  can, 
and  prevent  much  suffering  and  sorrow,  it  should  surely 
always  be  done  with  the  greatest  care,  and  in  the  best 
known  way.  The  success  of  all  operations  depends  on 
nice  care  and  management.  Operations  for  hernia  and 
for  stone,  for  instance,  if  roughly,  carelessly,  and  badly 
done,  end  badly:  so  it  is  with  vaccination ;  and,  so  far 
as  the  public  are  concerned,  it  is  quite  as  objectionable 
to  them,  no  doubt,  to  die  of  small-pox  because  they 
have  been  carelessly  and  badly  vaccinated,  as  it  would  be 
to  them  to  die  of  hernia  or  stone,  because  the  operations 
for  these  complaints,  respectively,  had  been  badly  per- 
formed. In  the  latter  cases  the  day  of  retribution 
would  come  immediately;  in  the  former,  unfortunately 
for  its  correction,  it  is  delayed  for  perhaps  twenty  years 
or  more;  otherwise  it  would  soon  be  set  right."* 

74.  Insusceptibility  to  Vaccination.  —  Insuscepti- 
bility to  the  infection  of  cow-pox,  even  for  a  very  limited 
period,  is  an  occurrence  of  excessive  rarity.  For  in  the 
few  cases  in  which  good  operators  fail  to  infect  at  the 
first  operation,  they  rarely  fail  at  a  second  trial  ;f  but 
now  and  then,  however,  a  second  attempt  may  not  suc- 
ceed, and  even  a  third  operation  may  not  take.  But 
supposing  vaccination  to  have  been  performed  by  a 
practiced  hand,  and  with  lymph  direct  from  the  arm, 

*  Article  "  Small-pox,"  in  System  of  Medicine,  edited  by  J. 
R.  Reynolds,  M.D.,  vol.  i.  p.  470. 

f  Of  upwards  of  9000  vaccinations  performed  at  the  Black- 
friars'  station  of  the  National  Vaccine  Establishment  since 
1859,  there  has  been  but  one  case  which  on  a  second  trial  was 
unsuccessful.  In  this  case  a  third  attempt  was  made,  but  the 
child  was  not  brought  back  for  inspection,  and  the  result  is 
unknown. 


•    INSUSCEPTIBILITY.  19T 

three  successive  weeks  without  result,  it  may  be  fairly 
assumed  that  there  is  temporary  insusceptibility.  Cases 
are  recorded,  and  others  have  been  stated  to  me  on 
authority  on  which  I  can  rely,  but  I  have  never  met 
with  any  myself,  in  which  persons  have  by  skillful 
hands  been  vaccinated  again  and  again,  at  intervals  of 
months  and  years,  without  the  vaccination  taking  effect. 
We  are  not,  however,  to  infer  from  this  that  the  insus- 
ceptibility was  permanent,  and  still  less  that  the  per- 
son was  at  all  safe  from  small-pox.  We  do  not  know 
even  that,  while  the  insusceptibility  to  vaccination 
lasts,  there  is  in  all  persons  corresponding  insuscepti- 
bility to  small-pox,  though  this  may  very  probably  be 
the  case.*  But  supposing  this  to  be  so,  a  change  of 
constitution  may  assuredly,  at  some  quite  indeterm- 
inate and  unknown  period,  render  the  hitherto  insus- 
ceptible person  susceptible  to  one  or  the  other,  probably 
to  whichever  he  may  be  first  exposed,  of  these  infec- 
tions, f 

*  The  late  Mr.  Spurgin,  of  Northampton,  forwarded  some 
years  ago  to  the  Epidemiological  Society  the  particulars  of  a 
case  in  which,  in  1825,  a  hoy  fourteen  years  old,  whose  family 
were  greatly  opposed  to  vaccination,  was  inoculated  with 
variola  six  or  seven  times  without  any  result,  that  disease 
heing  then  prevalent.  The  father  then  allowed  vaccination  to 
be  tried,  and  the  boy  was  vaccinated  six  or  seven  times,  but 
equally  without  effect.  About  a  year  after,  when  at  a  distance 
from  home,  he  contracted  natural  small-pox  of  the  discrete 
kind,  and  went  through  the  disease  favorably.  And  the  late 
Mr.  Marshall,  of  Kinton,  Herefordshire,  in  a  communication 
to  the  same  Society,  stated  that  in  two  cases  which  resisted 
vaccination  he  tried  small-pox  inoculation  and  found  it  equally 
resisted. 

f  See  Marson's  Article  "  Small-pox,"  in  System  of  Medicine 
(op.  cit.);  especially  the  very  interesting  case,  related  at  p. 


198  HANDBOOK  OF   VACCINATION. 

In  the  very  interesting  returns  of  the  Registrar- Gen- 
eral for  Scotland,  relating  to  the  vaccination  of  children 
under  the  law  in  force  in  that  kingdom,  I  find  that 
rather  more  than  one  in  200  of  the  children  vaccinated 
(0-69  per  cent,  in  1864,  and  0-41  per  cent,  in  1865)  are 
returned  to  the  Registrars  as  constitutionally  insus- 
ceptible of  vaccination.  The  term,  of  course,  in  these 
cases  is  only  to  be  taken  as  used  in  a  legal  sense,  and 
as  merely  implying  that  the  children  have  undergone 
the  three  successive  vaccinations  which  the  Act  re- 
quires to  be  performed  before  a  parent  is  entitled,  under 
a  certificate  of  insusceptibility,  to  exemption  from  the 
penal  provisions  of  the  law.  No  doubt,  the  insecurity 
of  these  children  against  future  small-pox  was  well 
explained  by  the  medical  practitioners  to  the  respective 
parents.  Still,  such  a  proportion  of  failures  as  this 
return  shows  is  a  misfortune ;  it  indicates,  even  with 
every  allowance  for  the  disadvantages  under  which, 
from  the  scattered  nature  of  the  population,  vaccina- 
tion must  be  earned  on  in  a  great  portion  of  Scotland, 
a  performance  of  vaccination  which  is  not  satisfactory. 
The  very  considerable  diminution,  however,  in  the  pro- 
portion of  these  cases  in  the  second  of  the  two  years, 
is  gratifying  and  encouraging. 

450,  of  a  woman,  aged  83,  dying  of  confluent  small-pox,  who 
had  nursed  her  own  children  and  her  grandchildren  with  the 
disease,  and  had  otherwise  often  been  exposed  to  variolous  in- 
fection, but  never  before  taken  it.  She  had  never  been  vac- 
cinated nor  inoculated. 


ALLEGED  DEGENERATION  OF  LYMPH.      199 


CHAPTER    X. 

OF  ALLEGED  DEGENERATION  OP  LYMPH,  AND  OF  RE- 
CURRENCE TO  THE  COW. 

75.  Will  Lymph  degenerate  if  due  care  be  em- 
ployed? Jenner's  opinion  on  the  subject. — It  has 
been  held  by  many  that  vaccine  lymph  degenerates, 
deteriorates,  or  loses  something  of  its  active  power, 
merely  by  passing  through  a  succession  of  human 
bodies.  This  hypothesis  dates  from  a  very  early  pe- 
riod of  the  history  of  vaccination,  and  applications  for 
lymph  "  as  recent  from  the  cow  as  possible "  were 
made  to  Jenner  within  two  or  three  years  from  the 
promulgation  of  his  discovery.*  He  thought  it  of  no 
importance  whatever  to  comply  with  the  exact  terms 
of  such  requests,  for  he  was  well  satisfied  from  his  ex- 
perience at  that  time  that  no  such  deterioration  had 
then  taken  place.  Nor  did  he  think  it  likely  that  with 
proper  care  it  would  occur  at  all ;  though  this,  he  said, 
was  a  point  which  "  time  alone  can  determine. "f  Fur- 
ther experience — a  careful  watching  of  vaccination  for 
upwards  of  twenty  years  more,  during  which,  lymph, 
successively  transferred  from  subject  to  subject,  had 
undergone  no  change  whatever  in  its  qualities — fully 
satisfied  him  that  the  hypothesis  was  groundless. 

But,  in  so  deciding,  he  was  most  careful  to  draw  the 

*  Ring,  op.  cit.,  p.  458. 

f  Continuation  of  Facts,  etc.,  If 00,  p.  H>2. 


200  HANDBOOK  OF   VACCINATION. 

essential  distinction  between  deterioration  of  lymph  by- 
mere  successive  transmissions  (the  subjects  for  trans- 
ferring it  having  been  proper  ones),  by  mere  lapse  of 
time  since  it  was  taken  from  the  cow,  on  the  one 
hand,*  and  deterioration  by  transmission  through  un- 
selected  subjects,  through  subjects  not  fit  for  transfer- 
ring it,  on  the  other.  And  while  he  regarded  the 
former  as  an  utterly  erroneous  notion,  a  conjecture 
which,  as  he  said,  "  he  could  destroy  by  facts,"  he  did 
not  fail  to  point  out  the  danger  of  deterioration  from 

*"  Lively  aguments,"  says  Simon,  "for  the  necessary  de- 
generation of  the  vaccine  contagion  have  proceeded  on  a  belief 
that  the  original  cow-pox  at  each  vaccination  simply  dilutes 
itself  vrith  certain  passive  juices  of  the  vaccinated  body,  that  it 
thus  of  course  gets  weaker  and  weaker  at  every  stage,  till  at 
its  thirty-fifth  succession  it  is  reduced — according  to  Dr. 
Nicolai — to  at  least  the  8,809,458,688th  fraction  of  its  original 
power."  This  argument  founds  itself  on  a  radical  misappre- 
hension of  the  infective  process  in  question.  Wha't  essentially 
marks  the  infective  action  of  cow-pox,  small-pox,  and  similar 
morbid  poisons,  is,  that  under  their  fermentative  influence  some 
ingredient  of  the  infected  body  converts  itself  into  their  like- 
ness. The  material  contained  within  certain  vaccine  vesicles 
is  not  a  something  which  has  been  transfused  into  the  body, 
but  a  something  which  has  been  generated  within  it  by  a  spe- 
cific decomposition  of  its  own  proper  substance  ;  and  the  origi- 
nal lymph,  which  acted  as  a  ferment  to  this  process,  has  very 
probably  completed  its  decay  and  altogether  passed  from  the 
scene  before  those  new  vesicles  begin  to  show  themselves. 
Successive  dynamical  infections  do  not  imply  a  perpetuation 
(with  corresponding  infinitesimal  subdivision)  of  the  original 
efficient;  or  Nicolai's  argument  might  equally  have  been  used 
to  prove  that  the  power  of  human  procreation  could  not  but 
cease  soon  after  the  days  of  Adam."  (Preface  to  Papers  re- 
lating to  the  History  and  Practice  of  Vaccination,  p.  xxix.) 


ALLEGED   DEGENERATION    OF  LYMPH.      201 

want  of  proper  care  in  the  choice  of  subjects.  "  The 
matter,"  said  he,  writing  in  1816,  "may  undergo  a 
change  that  may  render  it  unfit  for  further  use  by  pass- 
ing even  from  one  individual  to  another,  and  this  was 
as  likely  to  happen  in  the  first  year  of  vaccination  as 
in  the  twentieth;"  but  that,  with  proper  care  and  at- 
tention, lymph  underwent  no  change,  was  proved,  he 
held,  by  the  fact  that  the  vesicles  he  was  then  pro- 
ducing were  "  in  every  respect  as  perfect  and  correct 
in  size,  shape,  color,  state  of  the  lymph,  the  period  of 
the  appearance  and  disappearance  of  the  areola,  its 
tint,  and  finally  the  compact  texture  of  the  scab,  as 
they  were  in  the  first  year  of  vaccination ;  and  to  the 
best  of  my  knowledge,  the  matter  from  which  they  are 
derived  was  that  taken  from  a  cow  about  sixteen  years 
ago.*" 

76.  The  Vesicles  produced  now  by  Jenner's  Lymph 
have  the  same  character  and  course  as  he  described. 
— Now,  if  lymph  could  thus  undergo  from  eight  to 
nine  hundred  transmissions  without  giving  any  evi- 
dence of  change,  it  seems  difficult  to  understand  why, 
in  equally  careful  hands,  and  with  similar  opportuni- 
ties of  choice,  it  should  not  remain  equally  unchanged 
after  an  indefinite  number  of  transmissions.  Accord- 
ingly, numerous  trustworthy  observers,  who  had 
watched  the  vaccine  disease  at  the  introduction  of 
vaccination,  on  comparing  what  they  had  then  seen 
with  the  effects  produced  by  lymph  of  the  earliest 
stocks  after  a  lapse  of  thirty  or  forty  years,  were  una- 
ble to   detect    the  slightest    difference   either  in  the 

*  Baron's  Life  of  Jenner,  vol.  ii.  p.  398. 
18 


202  HANDBOOK  OF   VACCINATION. 

course  or  character  of  the  vesicles.*  Exactly  the 
same  is  the  case  if  we  compare  with  Jenner's  descrip- 
tion the  course  of  the  vesicle  induced  at  the  present 
day  with  lymph  of  Jenner's  stock.  Marson  says  he 
has  frequently  produced  lately,  with  lymph  brought 
into  use  by  Jenner  more  than  fifty  years  since,  vaccine 
vesicles  which,  on  comparison,  exactly  correspond  with 
the  vesicles  sketched  in  Jenner's  original  work.f  Mr. 
Steele,  the  able  and  experienced  teacher  of  vaccination 
at  Liverpool,  states  that  the  lymph  he  is  now  using 
was  supplied  by  Jenner  himself,  and  is  producing  still 
precisely  the  results  it  developed  at  first.|  After  it  had 
been  more  than  fifty  years  in  use  there,  it  was  com- 
pared, side  by  side,  with  lymph  which  Ceely  had  taken 
from  a  cow  six  years  before,  and  which  he  guaranteed 
to  have  lost  none  of  its  activity ;  but  no  difference  be- 
tween the  effects  of  the  two  lymphs  was  detectible.§ 
The  lymph  now  in  use  throughout  the  stations  of  the 
National  Vaccine  Establishment  is,  if  not  exclusively, 
nearly  all  of  Jenner's  original  stock,  and,  from  daily 
opportunities  of  observation,  I  can  affirm  that  it  has 
not  lost  anything  of  its  infective  power,  ||  and  that  the 
vesicles  produced  by  it  correspond  accurately  in  their 
character  and  course  with  Jenner's  description.    Other 

*  See  Aikin,  London  Medical  Gazette,  vol.  xiii.;  also  Rap- 
port de  l'Academie  Royale  de  Medecine  sur  les  Vaccinations 
pendant  l'annee  1841. 

f  Art.  "Small-pox,"  in  System  of  Medicine  (op.  cit),  vol. 
i.  p.  476. 

%  Steele  in  Liverpool  Medico-Chirurgical  Journal,  1858. 

\  British  Medical  Journal,  1862,  vol.  i.  p.  275. 

||  I  have  hefore  adverted  (g  69)  to  its  not  failing  on  an  aver- 
age above  once  in  170  times. 


ALLEGED  DEGENERATION  OF  LYMPH.      203 

stocks  have  at  times  been  introduced  into  use  at  the 
Establishment,  but  they  were  found  to  present  no  ad- 
vantages, and  it  was  not,  therefore,  felt  necessary  to 
take  any  particular  pains  to  maintain  them.*  So  far 
as  the  correct  character  and  course,  and  the  energy  (if 
I  may  so  say)  of  the  vaccine  vesicle  are  evidences  of 
its  prophylactic  power  against  small-poy,  I  cannot  but 
concur  entirely,  from  personal  observation,  with  the 
statement  which  the  National  Vaccine  Board  made  in 
1854,  "that  the  vaccine  lymph  does  not  lose  any  of  its 
prophylactic  power  by  a  continued  transit  through 
successive  subjects,  and  that  it  is  a  fallacy  to  predicate 
the  necessity  of  resorting  to  the  original  source  of  the 
cow  for  a  renewed  supply,  "f 

77.  And  leave  the  same  kind  of  Cicatrices — Mar- 
son  states,  however,  that  he  has  found  the  cicatrices 
left  by  some  lymph  which  he  has  had  many  years  in 

*  Strange  notions  appear  to  be  entertained  abroad,  and  I 
have  seen,  I  think,  similar  statements  made  even  in  this  coun- 
try, that  lymph  has  only  been  kept  alive  and  in  a  state  of 
energy,  in  England,  by  renewals  from  the  cow, — that  typical 
vesicles  are  only  seen  in  consequence  of  such  renewal.  But 
this  is  a  very  erroneous  notion.  The  lymph  chiefly  in  use 
throughout  England  is  Establishment  lymph,  which  is,  mainly, 
Jenner's  lymph.  Ceely,  who  has  more  knowledge  of  the  cow- 
pox  in  the  cow,  and  the  effects  of  cow-lymph  on  the  human 
subject,  than  any  other  man  in  England,  was  requested  by  the 
Medical  Department  of  the  Privy  Council,  in  1862,  to  inspect 
all  the  stations  from  which  lymph  was  contributed  to  the  Es- 
tablishment. He  "met  with  abundant  evidence  of  the  per- 
fectly satisfactory  character  of  the  lymph  in  use."  (Fifth 
Annual  Report  of  Medical  Officer  of  the  Privy  Council,  p.  9.) 

f  Annual  Report  of  the  National  Vaccine  Establishment 
for  1854. 


204  HANDBOOK  OF   VACCINATION. 

use,  to  be  now  not  so  good  as  the  same  lymph  produced 
formerly.*  Whatever  may  have  been  the  cause  of  this 
change,  its  extent,  I  apprehend,  is  not  such  as  to  make 
him  doubtful  of  the  essential  qualities  of  the  lymph  re- 
maining unaltered,  or  I  am  quite  satisfied  that  he  would 
have  discontinued  the  stock.  The  observation,  coming 
from  such  a  quarter,  is  important:  still  I  cannot  think 
it  generally  applicable.  During  the  last  eight  years  I 
have  examined  the  vaccine  cicatrices  on  the  arms  of 
more  than  a  hundred  thousand  persons,  of  all  ages,  but 
chiefly  children  in  schools.  Taking  the  results  gener- 
ally, I  have  not  found  them  by  any  means  indicative 
of  progressive  deterioration  in  the  character  of  the 
vaccine  scar.  And  taking  particularly  districts  which 
had  good  vaccinators,  men  who  knew  their  work 
thoroughly  well,  and  who  did  it  with  lymph  got  origi- 
nally from  the  Establishment,  i.e.  with  lymph  of  Jen- 
ner's  stock,  I  have  found  the  marks  corresponding  ex- 
actly to  Willan's  delineatiou,  and  in  no  respect  inferior 
to  cicatrices  which  I  have  seen  on  the  arms  of  persons 
vaccinated  by  Jenner  himself,  or  by  his  well-known 
contemporary,  Dr.  Walker. 

78.  Lymph  accidentally  degenerated  should  always 
be  at  once  changed. — As  I  have  stated  elsewhere, f  I 
have  repeatedly,  in  the  course  of  my  official  and  other 
inquiries  into  vaccination,  met  with  lymph  in  use  of 
a  comparatively  feeble  and  inactive  kind.  It  would 
be  strange  indeed  if  this  had  not  been  so,  considering 
the  very  miscellaneous  way  in  which  practitioners  have 

*  Art.  "Small-pox,"  in  System  of  Medicine  (op.  cit.),\o\.  i. 
f  Art.    "Vaccination,"   in  System  of  Medicine  (op.  cit.), 
vol.  i. 


ALLEGED  DEGENERATION  OF  LYMPH.      205 

been  frequently  content  to  get  their  lymph  from  others, 
and  the  unfavorable  conditions  under  which  they  have 
sometimes  been  content  themselves  to  take  lymph.* 
But  in  recommending  a  change  of  stock,  I  have  always 
felt  it  enough  to  take  care  that  the  stock  substituted 
should  be  good  active  lymph,  and  have  never  troubled 
myself  as  to  the  time  which  had  elapsed  since  it  had 
come  from  the  cow.  Does  the  lymph  produce  the 
effect  which  has  been  described  (§  34)  as  the  normal 
effect  of  the  introduction  of  vaccine  lymph  into  the  sys- 
tem ?  That  is  really  the  only  practical  question.  My 
experience  tells  me  that  vaccinators  who  have  to  depend 
on  others  for  lymph  should  be  very  careful  to  whom 
they  apply :  and  it  tells  me  still  more,  that  when  they 
have  got  some  good  lymph  they  should  be  very  careful 
through  what  subjects  they  transfer  it. 

79.  Particular  Lymphs.  The  Passy  Lymph. — In 
1836,  a  stock  of  lymph  was  obtained  at  Passy,  in  the 
environs  of  Paris,  from  the  hand  of  a  milker  who  had 
contracted  the  cow-pox  casually  from  the  cow.f  It 
manifested,  In  the  most  marked  manner,  and  through 
many  transmissions,  the  peculiarities  already  described 
as  attending  the  early  transmissions  of  primary  lymph 
(§  42).  When  compared  with  the  old  stock  then  in 
use  at  the  Academie  de  Medecine,  it  was  found  to  be 
more  infective,  to  develop  vesicles  which  were  mani- 
festly finer,  to  produce  a  more  marked  and  more  dura- 
ble areola,  and  to  leave  better  cicatrices.  But  the 
lymph  with  which  this  comparison  was  made  was 
evidently  lymph  which,  from  some  cause  or  other,  had 

*  See,  for  illustrations,  pp.  151,  note,  157,  note,  etc. 

f  Bousquet,  Nouveau  Traite  de  la  Vaccine,  pp.  403-416. 

18* 


206  HANDBOOK  OF   VACCINATION. 

become  deficient  in  those  qualities  which  characterize 
active  lymph.  When  we  are  informed  that  the  vesicles 
produced  by  it  had  their  complete  development  with 
commencing  areola  by  the  seventh  day,*  were  at  this 
date  of  softish  consistence,  so  that  the  slightest  touch  of 
the  lancet  would  make  them  empty  themselves,  and 
yield  a  virus  which  had  already  lost  some  of  its  trans- 
parency (pour  peu  qu'on  y  touche  avec  la  lancette,  elle 
se  vide,  et  le  virus  qui  en  sort  est  deja  un  peu  louche), 
had  commenced  desiccation  by  the  ninth  day,  completed 
it  by  the  twelfth,  and  somewhere  from  the  fifteenth  to 
the  eighteenth  day  threw  off  small  crusts,  leaving  cica- 
trices which  at  the  end  of  some  months  were  scarcely 
to  be  discerned,  we  see  at  once  that  we  are  dealing 
with  a  lymph  very  different  from  the  ordinary  lymph- 
stocks  of  England,  and  one  which  could  not  too  soon 
be  changed.  And  probably,  some  recent  revelations 
with  regard  to  the  mode  of  collecting  lymph  for  the 
service  of  the  Academie  may  throw  some  light  on  the 
cause  of  this  degeneration. f 

*  I  am  doubtful,  from  M.  Bousquet's  description,  whether 
he  means  the  seventh  day,  including  the  day  of  vaccination, 
according  to  our  mode  of  counting  (or  the  day  before  the  day- 
week),  or  the  seventh  day  after  the  vaccination  (which,  as 
we  count,  would  be  the  eighth  day,  or  the  day-week  itself). 
If  the  latter,  the  course  would  in  this  respect  be  quite  normal. 

f  The  following  statement  by  M.  Blot,  publicly  made  at  a 
meeting  of  the  Academie  (January  15,  1865),  has  not  been 
challenged  :  "  Je  sais,  en  effet,  comment  les  choses  se  passaient 
a  1' Academie  jusqu'a  dans  ces  dernieres  annees,  et  meme  peut- 
etre  encore  aujourd'hui.  Nourri  pres  du  serail,  j'en  connais 
les  habitudes.  Comment  croyez-vous  qu'est  recueillie  une 
grande  partie  du  vaccin  qui  sert  a  1' Academie?  A  quelles 
sources  pensez-vous  qu'on  aille  le  puiser?     Par  quelles  mains 


ALLEGED  DEGENERATION  OF  LYMPH.      207 

When  this  Passy  lymph  of  1836  was  compared  with 
some  lymph  which  had  been  in  use  for  twenty-nine 
years  at  Tours,  it  exhibited  during  its  first  transmis- 
sions considerably  more  local  intensity  of  symptoms, 
but  in  a  very  short  time  this  peculiarity  declined,  and, 
at  the  end  of  a  year,  there  was  scarcely  the  slightest 
difference  perceptible  in  the  action  of  the  two  lymphs ; 
when,  in  1838,  it  was  compared  with  a  stock  then 
obtained  new  from  the  cow  at  Rouen,  such  difference 
as  was  noted  was  in  favor  of  the  older  (the  Passy) 
lymph  ;  when,  in  1841,  after  from  200  to  250  transmis- 
sions, it  was  compared  with  a  stock  from  the  cow  near 
Dijon,  or  with  some  lymph  from  Stuttgardt,  at  the 
first,  third,  and  twelfth  removes  from  the  cow,  it  was 

cette  recolte  si  importante  est-elle  faite?  Je  vais  vous  le  dire. 
Jusqu'cn  ces  derniers  temps,  voila  comment  les  choses  se  pra- 
tiquuient.  On  vaccinait  ici  deux,  trois,  quatre,  ou  cinq  enfants 
envoyes  par  la  surveillante  du  service  de  la  clinique  d'ac- 
couchement,  puis  ils  retournaient  a  la  clinique.  Au  bout  de 
huit  jours  on  allait  a  l'hopital  recueillir  ce  que  chacun  de  ces 
enfants  avait  pu  produire  de  liquide  vaccinal.  Or,  Messieurs, 
qui  croyez-vous  qui  allait  faire  cette  recolte,  dont  le  produit 
devait  servir  a  inoculer  d'autres  enfants,  soit  a  l'Academie, 
soit  dans  Paris,  soit  en  province  ?  M.  le  directeur  de  la  vac- 
cine, peut-etre?  Jamais.  A  son  defaut,  M.  le  sous-directeur  ? 
Pas  davantage.  Eh  bien,  alors,  direz-vous,  un  des  membres 
de  la  commission  permanente  de  vaccine  ?  Pas  tu  tout.  Alors 
quelque  jeune  medecin  distingue,  ou  tout  au  moins  un  interne? 
Vous  n'y  etes  pas  davantage.  C'etait un  simple  em- 
ploye des  bureaux  de  l'Academie,  un  vieillard  valetudinaire, 
completement  etrnnger  a  Part  de  guerir,  et  de  plus  atteint  do 
tremblement  senile.  Je  n'ai  pas  besoin  de  dire  si  ce  brave 
homme  tftait  capable  de  choisir  les  sujets,  d'examiner  et  d'in- 
terroger  les  meres.  En  tout  cas,  en  eut-il  ete  capable,  il  no 
sen  inquietait  nullement." 


208  HANDBOOK  OF   VACCINATION. 

as  active  as  either  of  them ;  and  when,  three  years 
later,  and  after  some  400  transmissions,  or  more,  it  was 
used,  in  1844,  side  by  side  with  some  lymph  just 
obtained  from  a  cow  belonging  to  M.  Majendie,  there 
was  absolutely  no  difference  in  the  action  of  the  two 
lymphs.  On  comparison,  by  various  experimenters,  of 
the  action  of  lymph  from  some  of  these  more  recent 
stocks — the  Rouen  stock,  and  Majendie's — with  lymph 
of  the  original  stocks  which  was  in  use  in  various 
places,  no  difference  was  detectible.* 

A  lymph-stock,  which  was  set  in  circulation  by  Mr. 
Estlin,  of  Bristol,  in  1838, f  produced  in  its  earliest 
transmissions  much  of  that  extreme  local  irritative 
effect  which  Jenner  and  others  describe  as  attending 
the  use  of  unhumanized  lymph,  and  which,  so  far  from 
regarding  as  an  advantage,  they  were  always  anxious 
to  control.  It  was  so  exceedingly  irritative,  that  I 
know  that  life  was  endangered  in  some  instances  by 
the  use  of  it,  and  I  rather  think  a  fatal  case  or  two 
occurred-!    When,  after  some  transmissions,  this  viru- 

*  See  Bousquet,  Nouveau  Traite,  etc.,  pp.  415-6:  also  Rap- 
port de  l'Academie  Royale  de  Medecine  de  Paris,  sur  les  Vac- 
cinations pratiquees  en  France  pendent  l'annee  1841  ;  ibid., 
1844;  ibid.,  1845.  s 

f  It  was  obtained  at  the  second  remove  from  a  little  child 
aged  five  years,  who  had  been  inoculated  with  a  needle  with 
the  discharge  proceeding  from  the  hands  of  a  milker  in  a 
dairy,  in  which  there  was  cow-pox.  (London  Medical  Gazette, 
vol.  xxii.) 

\  The  late  Mr.  Gilham,  of  the  National  Vaccine  Establish- 
ment, having  vaccinated  a  number  of  children  with  Estlin's 
lymph,  during  its  early  transmissions,  when  it  was  producing 
severe  local  effects,  tested  tbem  afterward  by  variolous  inocu- 
lation, and,  for  comparison's  sake,  inoculated  with  variola  an 


ALLEGED   DEGENERATION  OF  LYMPH.      209 

lence  abated,  it  was  a  fine  and  good  stock,  and  was  re- 
garded by  Mr.  Estlin  and  others  who  employed  it  as 
superior  to  the  lymph  they  were  then  respectively 
using.  As  the  stock,  however,  which  Mr.  Estlin  was 
then  using  is  described  by  him  as  producing  small 
vesicles,  running  a  rapid  course,  and  yielding  little 
lymph  of  diminished  infective  power,  it  is  clear  again 
that  the  comparison  was  made  with  lymph  very  differ- 
ent from  that  which  now,  thirty  years  later,  may  be 
found  in  current  use  at  our  best  public  stations,  pro- 
ducing perfect  results,  and  not  failing  once  in  a  hun- 
dred and  seventy  times.*  When  Mr.  Aikin  compared 
Estlin's  lymph  with  some  he  had  in  use  from  Jenner's 
original  stock,  he  could  not  detect  any  difference.-}" 

In  the  dairy  farms  of  the  Bridgewater  Level  and  of 
the  A' ale  of  Gloucester,  the  natural  cow-pox  is  still  not 


equal  number  of  children  who  had  been  vaccinated  by  him 
with  lymph  of  Jenner's  old  stock.  Both  series  resisted  equally 
the  action  of  the  variolous  inoculation. 

*  Mr.  Estlin  considered  it  important  testimony  that  at  the 
Vaccine  Institution  at  Glasgow  his  lymph  had  not  failed  once 
in  43  trials,  while  in  the  preceding  43  vaccinations  there  had 
been  10  failures  and  9  spurious  or  imperfect  results  ;  and  at  the 
time  the  new  supply  reached  them  "  all  the  children  vaccinated 
on  the  day-week  preceding  presented,  instead  of  true  vesicles, 
raw  surfaces  resembling  spots  that  had  been  vesicated  and  then 
denuded  of  their  cuticle."  Surely  there  is  nothing  here  proved, 
but  the  worthlessness  of  the  stock  of  lymph  (?)  they  bad  in 
use.  I  do  not  know  what  is  the  Institution  referred  to  as  the 
Vaccine  Institution  at  Glasgow,  but  I  do  happen  to  know  that 
at  the  Royal  Infirmary  of  that  city  in  bygone  days  an  occa- 
sional, if  not  a  frequent,  performer  of  the  vaccination  was  the 
hospital  porter. 

f  London  Medical  Gazette,  vol.  xxvi.  p.  189. 


210  HANDBOOK  OF   VACCINATION. 

infrequent,  and  inoculations  direct  from  the  cow  have 
been  practiced  in  several  districts  with  success.  "All 
who  have  employed  such  lymph  agree  in  stating  that, 
after  the  first  or  second  transmission,  the  results  ob- 
tained do  not  differ  from  those  of  ordinary  vaccination, 
either  in  respect  of  the  progress  or  character  of  the 
vesicle."* 

The  comparison  of  the  Passy  lymph  with  other 
lymphs  direct  from  the  cow,  tends,  indeed,  to  show 
that  all  primary  stocks  are  not  identical  in  their  local 
action  on  the  human  subject;  but  there  is  nothing 
whatever  to  show,  or  to  lead  even  to  a  probable  infer- 
ence, that  the  points  in  which  they  differ  are  in  the 
least  essential.  Mr.  Ceely,  writing  in  1841,  tells  us, 
that  during  the  preceding  three  years  he  had  observed 
and  noted  the  effects  on  a  variety  of  subjects,  of  more 
than  fifteen  different  stocks  of  vaccine  lymph,  of  which 
six  had  been  from  the  natural  disease,  either  taken 
direct  from  cows  or  from  vesicles  on  the  hands  of 
milkers,  and  seven  artificially  produced  in  the  cow. 
These  stocks  had  all  varied  in  their  effects,  both  locally 
and  constitutionally,  but  none  had  lacked  the  essential 
qualities  and  properties,  nor  had  any  possessed  them 
in  a  superior  degree  to  those  indicated  in  the  descrip- 
tion and  illustrations  of  Jenner.  This  is  the  "stand- 
ard," he  says,  "to  which  we  may  at  all  times  confidently 
appeal. "f  "  My  own  repeated  applications  to  the  cow" 
(for  lymph),  he  tells  us  elsewhere,  "  have  been  chiefly 
for  the  purpose  of  experiment,  for  the  satisfaction  of 

*  Sanderson,  quoted  in  Sixth  Report  of  Medical  Officer  of 
Privy  Council,  p.  10. 

f  Trans.  Provincial  Medical  and  Surgical  Association,  vol. 
x.  p.  261. 


PROTECTION  AGAINST  SMALL-POX.         211 

patients  or  the  accommodation  of  friends,  not  from  any 
belief  in  its  superior  efficacy  over  active  humanized 
lymph."* 


CHAPTER    XI. 

OP   THE   PROTECTION   WHICH   VACCINATION   AFFORDS 
AGAINST   SMALL-POX. 

80.  What  Small-pox  was  before  the  Discovery  of 
Vaccination.  —  Until  the  close  of  the  last  century, 
small-pox  was  by  far  the  most  formidable  and  fatal 
of  all  the  diseases  that  afflicted  mankind.  The  great 
and  eloquent  modern  historian  of  England,  comparing 
the  ravages  it  made  in  this  country  toward  the  close 
of  the  seventeenth  century — when,  among  others, 
JVIary,  the  wife  of  William  III.,  fell  a  victim  to  it — 
with  the  ravages  of  the  plague,  justly  assigned  to 
small-pox  the  foremost  place,  as  "the  most  terrible  of 
all  the  ministers  of  death."  "  The  havoc  of  the  plague," 
says  Macaulay, "  had  been  far  more  rapid,  but  the  plague 
had  visited  our  shores  only  once  or  twice  within  living 
memory,  but  the  small-pox  was  always  present,  filling 
the  churchyards  with  corpses,  leaving  on  those  whose 
lives  it  spared  the  hideous  traces  of  its  power,  turning 
the  babe  into  a  changeling  at  which  the  mother  shud- 
dered, and  making  the  eyes  and  cheeks  of  the  betrothed 

*  Trans.  Provincial  Medical  and  Surgical  Association,  vol. 
viii.  p.  376. 


212  HANDBOOK  OF   VACCINATION. 

maiden  objects  of  horror  to  the  lover."*  This  descrip- 
tion applied  with  at  least  equal  force  a  hundred  years 
later.  Few  indeed,  then,  were  those  who  were  not 
at  some  time  or  other  of  their  lives  attacked  by  this 
fell  disease  ;  and  happy  was  it  for  any  one  so  attacked 
that  he  should  escape  with  life,  or  with  unimpaired 
health,  or  without  serious  disfigurement.  I  must  refer 
to  others  for  a  description  of  the  ravages  small-pox 
made  in  other  countries  :f  in  England,  according  to 
the  calculation  of  Dr.  Lettsom,  the  average  annual 
deaths  from  it  were  about  3000  out  of  every  million  of 
the  population ; \  a  death-rate  which,  with  the  present 
population  of  the  kingdom,  would  give  an  average  of 
considerably  more  than  sixty  thousand  deaths  from 
small-pox  a  year.  Nearly  one-tenth  part  of  all  the 
persons  who  died  in  London,  within  the  bills  of  mor- 
tality, during  the  last  half  of  last  century,  died  of  this 
one  cause. §  The  younger  part  of  the  population  were 
peculiarly  its  victims;  in  some  of  our  great  cities  it 
was  found  that,  on  an  average  of  long  series  of  years, 

*  Macaulay,  Hist,  of  England,  vof.  iv.  p.  530  (8vo.  edit. 
1855). 

•j-  See  particularly  the  most  interesting  account  given  by 
Simon,  Preface  to  Papers  relating  to  the  History  and  Prac- 
tice of  Vaccination,  pp.  ii.-vii.;  see  also  Baron's  Life  of  Jen- 
ner,  vol.  i.  pp.  256-272 ;  and  Moore's  History  of  Small-pox. 

J  A  calculation,  separately  made,  by  Sir  Gr.  Blane,  corre- 
sponded very  closely  with  Lettsom's.  (See  "  The  Evidence  at 
Large,  as  laid  before  the  House  of  Commons,"  etc.,  by  the  Kev. 
G.  C.  Jenner.) 

\  90  per  1000;  see  Report  on  Small -pox  and  Vaccination, 
presented  to  the  President  and  Council  of  the  Epidemiological 
Society,  by  the  Small-pox  and  Vaccination  Committee,  1853 
(8vo.  edit.),  p.  42. 


PROTECTION  AGAINST  SMALL-POX.         213 

nearly  or  more  than  one-third  of  all  the  deaths  which 
took  place  in  children,  under  ten  years  of  age,  arose 
from  small-pox.*  The  mutilations  which  it  caused, 
when  it  did  not  slay,  were  so  frequent  and  so  consid- 
erable, that  we  have  it  on  record  that  at  the  period  of 
which  we  are  speaking,  two-thirds  of  the  applicants  for 
relief  at  the  Hospital  for  the  Indigent  Blind  owed  their 
loss  of  sight  to  small-pox  -f  and  we  need  but  refer  to 
the  writings  of  physicians  of  that  time,  to  see  how 
frequently  it  was  followed  by  deafness,  and,  in  consti- 
tutions disposed  to  scrofula,  by  glandular  swellings, 
obstinate  ulcerations,  and  other  evidences  of  the  devel- 
opment of  that  disease. 

81.  The  Characters  of  Small-pox,  when  uncontrolled 
by  Vaccination,  are  still  the  same. — It  is  quite  neces- 
sary to  recall  these  facts,  because,  as  has  been  well 
remarked,  since  by  the  introduction  of  vaccination, 
small-pox  has  almost  ceased  to  be  a  fatal  disease 
among  the  civilized  classes  of  society,  there  is  to  them 
"  a  temptation  to  forget  how  their  fathers  and  grand- 
fathers regarded  it.  "J  If  we  could  only,  for  a  moment, 
suppose  that  the  protection  against  small-pox,  which 
our  population  now  enjoys  from  vaccination,  were  all 
at  once  removed,  it  is  beyond  a  doubt  that  we  should 
find  ourselves  thrown  back  into  all  the  horrors  of  last 
century.     For  the  small-pox  itself  appears  to  have  lost 

*  In  Glasgow,  from  1783-1792,  36  per  cent.,  and  from  1793- 
1802,  32  per  cent.,  of  all  the  deaths  under  ten  years  of  age 
were  deaths  from  small-pox.  (See  Cowan's  Vital  Statistics  of 
Glasgow.) 

f  Sir  G.  Blane  in  Medico-Chirurg.  Trans.,  vol.  x.  p.  326. 

X  Simon,  op.  cit,  p.  ii. 

19 


214  HANDBOOK  OF   VACCINATION. 

nothing  of  its  malignancy  and  fatality,  either  by  lapse 
of  time,  or  (since  Sydenham's  day)  by  any  improve- 
ment in  medical  treatment.  We  find  from  the  records 
of  the  Small-pox  Hospital  that,  during  the  last  25 
years  of  last  century,  the  death-rate  in  the  hospital 
(the  patients,  of  course,  being  all  unvaccinated)  was 
32i  per  cent,  of  the  admissions.*  In  the  same  hos- 
pital, during  the  years  1836-51,  the  deaths,  excluding 
the  vaccinated,  were  35  per  cent.f  Dr.  Jurin,  writing 
early  in  last  century,  laid  it  down  as  the  result  of  his 
investigations,  "that  of  persons  of  all  ages,  taken  ill  of 
natural  small-pox,  there  will  die  of  that  distemper  one 
in  five  or  six."!  From  returns  made  to  the  Epidemio- 
logical Society  in  1852,  by  156  medical  practitioners 
in  various  parts  of  England,  who  had  kept  numerical 
records  of  their  small-pox  experience,  it  appeared  that 
the  proportion  of  deaths  to  cases  which  they  had  met 
with  in  the  natural  form  of  the  disease,  was  19  7  per 
cent.,  or,  as  nearly  as  possible,  one  to  five — a  result 
which  closely  corresponds  with,  and  is  certainly  in  no 

*  As  given  in  Appendix  to  the  Annual  Keport  of  the  Na- 
tional Vaccine  Board,  printed  by  order  of  the  House  of  Com- 
mons, March  2,  1826. 

f  See  table  I.  in  Marson's  Papers  on  Small-pox  and  Vacc. 
in  .Medico-Chir.  Trans.,  vol.  xxxvi.  I  apprehend  it  is  hardly 
necessary  to  say  that  it  would  not  be  at  all  a  fair  inference, 
from  the  somewhat  higher  death-rate  of  the  later  period,  that 
the  small-pox  had  become  worse;  probably,  in  the  earlier 
period,  some  cases  of  the  inoculated  small-pox  (a  comparatively 
little  fatal  disease)  are  included.  But  these  would  have  con- 
stitated  but  a  small  proportion  of  the  whole,  and  it  is  a  fair 
inference  from  the  figures,  as  they  stand,  that  the  fatality  of 
the  natural  disease  has  undergone  no  essential  change. 

|  Moore's  History  of  Small-pox,  p.  243. 


PROTECTION  AGAINST  SMALL-POX.         215 

degree  more  favorable  than  that  of  Dr.  Jurin.*  And 
the  same  sequelae  which  Willan  describes  as  attending 
the  natural  suiall-pox  in  his  time,  attend  the  natural 
small-pox  now.  If,  further,  we  look  to  see  what  has 
happened  when,  in  recent  times,  small-pox  has  invaded 
or  invades  populations  among  whom  vaccination  has 
been  but  little  practiced,  we  find  its  ravages  to  be  ex- 
actly like  those  met  in  Europe  during  last  century. 
This  was  the  case  in  1846-8,  in  an  epidemic  which 
occurred  in  the  Argentine  Confederation,  and  which  is 
described  by  Dr.  Makenna — a  British  physician,  then 
practicing  at  Montevideo  —  as  sweeping  with  the 
wings  of  death  over  that  enormous  tract  of  country, 
which  extends  from  the  seaboard  of  the  Atlantic  on 
the  east  to  the  Corderilla  of  the  Andes  on  the  west. 
"Throughout  this  whole  space,"  he  observes,  "it  may 
be  said  that  hardly  a  single  house  or  rancho  escaped 
its  fearful  visitation,  wherever  the  current  of  human 
intercourse  reached ;  and  such  was  its  fatality,  that  I 
have  known  thirty  children  taken  in  one  morning  from 
the  houses  of  one  quadra  of  a  street  150  yards  long, 
and  I  have  seen  two  men  above  seventy  years  of  age, 
and  deeply  pitted  with  a  former  attack,  carried  off  by 
it.     Whole  families  were  swept  away,  and,  in  short, 

*  Seaton,  Protective  Power  of  Vaccination,  San.  Kev.,  vol. 
ii.  p.  354.  These  returns  must  be  looked  upon  as  very  favor- 
able, because  they  did  not  include  any  severe  epidemics  in 
large  towns.  In  such  epidemics  the  proportion  of  fatal  cases 
is  frequently  one  in  four,  or  greater.  (See  p.  238,  note.)  In 
the  Small-pox  Hospital  the  mortality  is  still  higher — partly, 
no  doubt,  because  it  is  for  the  severer  cases  of  disease  that 
hospital  accommodation  is  peculiarly  sought,  and  partly  also 
on  account  of  hospital  influence. 


216  HANDBOOK  OF   VACCINATION. 

the  terrors  of  the  plagues  of  former  times  were,  if  not 
surpassed,  fully  equaled  by  this  horrible  scourge.  .  .  . 
But  that  which  struck  me  as  most  truly  remarkable 
was,  that  not  one  of  those  English  people  who  had 
been  vaccinated  at  home,  and  who  had  the  large,  deep, 
oval  thimble-mark  on  one  or  both  arms,  ever  took  the 
disease."*  In  Japan,  at  the  present  time,  where, 
though  vaccination  is  known,  it  is  practiced  to  a  very 
limited  extent  only,  "small-pox  is  endemic  and  ex- 
tremely prevalent.  It  is  very  rare,  indeed,"  says  Mr. 
Dickins,  "to  meet  a  man  on  whose  face  there  are  not 
some  marks  of  the  disease  left.  A  very  large  propor- 
tion die,  and  a  much  larger  proportion  are  horribly 
marked,  as  a  very  short  walk  through  the  town  or 
country  will  convince  the  inquirer It  very  fre- 
quently attacks  the  eyes,  and  when  it  does,  blindness 
is  almost  an  inevitable  result.  Almost  every  'Amma,' 
or  blind  beggar,  of  whom  I  made  inquiry  as  to  the 
cause  of  his  blindness,  told  me  that  it  was  the  result 
of  sm  all-pox.  "f 

82.  Introduction  of  Variolous  Inoculation :  its  Re- 
sults.— An  attempt  made  early  in  the  last  century  to 
mitigate  the  ravages  of  this  disease  was  found  but  to 
extend  its  deadly  influence.  The  practice  of  inocu- 
lating into  the  skin  the  matter  of  small-pox,  which  had 
been  long  known  in  Eastern  countries,  was  introduced 
into  England  in  1121,  through  the  advocacy  and  exam- 
ple of  Lady  Mary  Wortley  Montague. J     It  purposed, 

*  Australian  Medical  Journal,  January,  1858. 

f  Statistical  Keport  of  the  Health  of  the  Navy  for  1864,  pp. 
242,  243. 

%  Inoculation  by  rubbing  the  matter  of  small-pox  on  the 
skin  of  the  arm,  or  pricking  the  skin  with  pins  or  other  pointed 


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-aopun  ■juauuaj  si 
eiquoildxoui  pun  ; 

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218  HANDBOOK  OF   VACCINATION. 

process  was,  indeed,  far  from  being  absolutely  void  of 
danger;*  but,  relatively  to  the  natural  disease,  the  dan- 
ger was  so  slight,  and  the  obvious  advantages  of  inocula- 
tion to  the  individual  were  consequently  so  great,  that 
the  practice,  having  been  at  first  hesitatingly  accepted, 
afterward  made  considerable  progress.  But  just  in  pro- 
portion to  this  progress  did  the  one  great  and  fatal 
drawback  to  the  use  of  variolous  inoculation  become  ap- 
parent. It  was  found  that  it  multiplied  the  foci  of  con- 
tagion: the  small-pox  produced  by  inoculation  was  as 
capable  of  conveying  infection  as  the  natural  small- 
pox-itself;  and  as  it  was  not  in  most  instances  severe 
enough  to  confine  the  patient  either  to  his  bed  or  to  his 
house,  while  free  exposure  to  the  air  was  justly  re- 
garded as  the  best  mode  of  treatment,  it  is  obvious 
how,  especially  in  large  towns,  the  chances  of  infection 
must  have  been  multiplied.  Besides,  as  small-pox 
could  thus  be  set  agoing  anywhere  by  merely  sending 
a  bit  of  cotton-thread  dipped  in  variolous  lymph  for  the 
purpose  of  inoculation,  it  was  constantly  being  intro- 
duced into  places  from  which  otherwise  it  might  have 
been  long  absent.  Hence  the  general  mortality  from 
small-pox  after  the  practice  of  inoculation  had  become 
diffused  was  considerably  greater  than  it  had  been  be- 
fore that  practice  was  known.  "However  beneficial," 
says  the  Royal  College  of  Physicians  of  London,  in 

*  In  the  early  experiments  with  inoculation  in  England, 
the  deaths  resulting  from  the  process  were  two  per  cent,  of  the 
operations  performed ;  hut  this  death-rate  was  subsequently 
greatly  diminished  when  the  management  of  inoculation  he- 
came  better  understood,  and  Dr.  Gregory  gives  three  in  a 
thousand  as  the  average  of  deaths  from  inoculation  at  the 
Small-pox  and  Inoculation  Hospital. 


PROTECTION  AGAINST  SMALL-POX.         219 

'their  Report  on  Vaccination  (1807),  "the  inoculation 
of  small-pox  may  have  been  to  individuals,  it  appears 
to  have  kept  up  a  constant  source  of  contagion,  which 
has  been  the  means  of  increasing  the  number  of  deaths 
by  what  is  called  the  natural  disease.  It  cannot  be 
doubted  that  this  mischief  has  been  extended  by  the 
inconsiderate  manner  in  which  great  numbers  of  per- 
sons, even  since  the  introduction  of  vaccination,  are 
still  every  year  inoculated  with  the  small-pox,  and  af- 
terward required  to  attend  two  or  three  times  a  week 
at  the  places  of  inoculation,  through  every  stage  of 
their  illness."*  It  is  stated  by  Dr.  Heberden  that 
while,  out  of  every  thousand  deaths  from  all  causes 
within  the  bills  of  mortality,  the  small-pox  deaths 
during  the  first  thirty  years  of  the  eighteenth  century, 
before  inoculation  could  yet  have  had  any  effect  upon 
them,  amounted  to  seventy-four ;  they  amounted  during 
an  equal  number  of  years,  at  the  end  of  the  century, 
to  ninety-five,  showing  an  increase  in  the  proportion  of 
about  five  to  four.  It  was  becoming  evident,  there- 
fore, that  unless  inoculation  could  be  made  by  compul- 
sion universal,  it  would  be  better  for  the  community 
that  it  should  be  abandoned  altogether. 

83.  Discovery  of  Vaccination. — Such  was  the  appa- 
rently hopeless  condition  of  things  when,  toward  the 
close  of  the  century  (in  1798),  .Tenner  made  known  to 
the  world  that  he  had  discovered  and  matured  a  pro- 

*  Papers  relating  to  the  History  and  Practice  of  Vaccina- 
tion, p.  7.  In  France,  in  consequence  of  the  multiplication  of 
foci  of  infection  through  inoculation,  a  royal  decree  prohib- 
ited, in  17G3,  the  practice  altogether,  "dans  1 'enceinte  des 
villes  et  des  faubourgs."  (Kapport  de  l'Acad.  Imp.  etc.,  sur 
les  Vaccinations  en  1858-9.) 


220  HANDBOOK  OF   VACCINATION. 

cess   by  which   persons   might  be   protected  against' 
small-pox  without  any  danger  to  themselves  and  with- 
out any  risk  of  infecting  others. 

Thirty  years  before,  when  he  was  apprentice  to  a 
surgeon  at  Sodbury,  in  the  County  of  Gloucester,  a 
young  countrywoman  had  said  in  his  hearing  that  she 
could  not  take  small-pox,  "for  she  had  had  cow-pox." 
These  words  riveted  his  attention,  and  the  impression 
they  made  was  never  effaced.  He  found  that  in  that 
county,  where  cow-pox  was  frequently  met  with  among 
the  dairies,  and  where  the  milkers  were  continually 
getting  accidentally  infected  from  the  sores  on  the  cows' 
teats,  the  notion  was  widely  diffused,  though  appa- 
rently of  no  very  long  standing,  that  such  of  them 
as  had  been  thus  infected  were  insusceptible  of  small- 
pox.* A  careful  investigation  of  the  grounds  of  this 
belief  enabled  him  both  to  establish  its  general  truth, 
and  satisfactorily  to  explain  and  account  for  the  appa- 
rent exceptions;  and  it  was  during  these  inquiries, 
continued  for  many  years,  that  his  genius  conceived 
the  idea  that  not  only  might  the  cow-pox  be  given  at 
will  to  man  by  the  process  of  inoculation  from  the  cow 

*  "At  what  period  the  cow-pox  was  first  noticed  here  is  not 
upon  record.  Our  oldest  farmers  were  not  unacquainted  with 
it  in  their  earliest  days,  when  it  appeared  among  their  farms 
without  any  deviation  from  the  phenomena  which  it  now  ex- 
hibits. Its  connection  with  the  small-pox  seems  to  have  been 
unknown  to  them.  Probably  the  general  introduction  of  in- 
oculation first  occasioned  the  discovery."  (Jenner,  Inquiry 
into  the  Causes  and  Effects,  etc.,  p  64.)  The  belief  among 
dairy-folk  of  the  antivariolous  powers  of  cow-pox  existed  in 
other  parts  of  England,  as  well  as  in  Ireland,  parts  of  Ger- 
many, etc.  (See  Ring,  Treatise  on  the  Cow-pox;  and  see 
also  Simon,  op.  cit.,  p.  xii.) 


PROTECTION  AGAINST  SMALL-POX.         221 

whenever  opportunity  offered,  but  that  it  might  be 
transferred  and  continued  by  that  process  from  one 
human  subject  to  another,  and  that  in  this  way  protec- 
tion against  small-pox  might  be  imparted  to  mankind 
in  perpetuity. 

As  early  as  1780,  he  communicated  to  his  friend  Ed- 
ward Gardner  the  views  he  had  been  led  to  entertain 
on  this  subject,  but  it  was  not  till  sixteen  years  later 
that  (in  1796)  he  was  able  to  put  these  views  to  ex- 
perimental proof.  With  what  trembling  anxiety  must 
Jenner  have  watched  these  first  experiments  !  What  de- 
light must  he  have  felt  when  he  saw  that  the  great  an- 
ticipations he  had  expressed  to  Gardner  were  about  to 
be  realized !  Circumstances,  however,  obliged  him  to 
suspend  his  experiments  for  awhile,  but  early  in  1798 
he  was  able  to  resume  them ;  and  by  the  summer  of 
that  year  he  had  established  his  great  discovery  on  so 
ample  a  basis  of  observation  and  experiment  that  he  felt 
the  time  was  come  for  making  it  known  to  the  world. 

84.  Its  Protective  Power  against  Small-Pox  dem- 
onstrated.— The  "  Inquiry  into  the  Causes  and  Effects 
of  the  Variola?  Vaccinae" — for  so  the  first  tract  he  pub- 
lished on  the  subject  was  entitled — has  been  justly 
called  by  one  well  qualified  to  judge  a  "masterpiece 
of  medical  induction  "*  In  this  treatise  Jenner  proved 
that  the  natural  cow-pox,  casually  communicated  to  man, 
rendered  him  insusceptible  of  taking  small-pox,  whether 
by  inoculation  or  by  infection;  that  this  protective 
power  was  not  lost  by  lapse  of  time,  but  manifested 
itself  at  the  end  of  twenty,  thirty,  or  even  fifty  years  ; 
that  it  was  possessed  by  the  genuine  cow-pox  alone, 
and  not  by  other  eruptions  to  which  the  cow  was  sub- 

*  Simon,  op.  cit.,  p.  xii. 


222  HANDBOOK  OF   VACCINATION. 

ject,  and  which  might  be  confounded  with  it ;  that  the 
cow-pox  might  be  communicated  at  will,  to  man,  by 
the  hand  of  the  surgeon,  whenever  the  requisite  oppor- 
tunity offered  ;  that,  once  engrafted  on  the  human  sub- 
ject, it  might  be  continued  from  individual  to  individual 
by  successive  transmissions ;  and  that  so  transmitted 
it  conferred  on  each  individual  the  same  immunity  from 
small-pox  as  was  enjoyed  by  the  one  first  infected  direct 
from  the  cow.  The  disease  had  then,  indeed,  only 
been  conveyed  from  human  subject  to  human  subject, 
through  five  successive  transmissions;  but  as  the  child 
last  vaccinated  had  been  submitted  to  the  variolous  in- 
fection, and  resisted  it,  equally  with  the  one  who  had 
been  vaccinated  direct  from  the  cow,  reason  and  analogy 
rendered  it  difficult  to  doubt  that  this  transmission 
might  be  perpetually  maintained.  In  two  years  more 
Jenner  was  able  to  report  that  upwards  of  6000  persons 
had  been  inoculated  with  the  virus  of  cow-pox,  con- 
veyed through  a  succession  of  human  subjects,  "  and 
the  far  greater  part  of  them  have  since  been  inoculated 
with  that  of  small-pox,  and  exposed  to  its  infection  in 
every  rational  way  that  could  be  devised,  without 
effect."*  It  is  in  the  successive  transmission  of  cow- 
pox  through  human  subjects  that  the  practical  useful- 
ness of  Jenner's  great  discovery  lies ;  and  since  the 
process  was  first  made  known  by  him,  all  ordinary 
vaccinations  have  been  thus  carried  on. 

85.  Jenner's  opinion  as  to  the  Degree  of  Protection 
it  afforded. — The  protection  which  vaccination  would 
afford  against  small-pox  was  held  by  Jenner  to  be  ex- 


*  A  Continuation  of  Facts  and  Observations,  etc.,  by  E. 
Jenner,  M.D.     Lond.  1800. 


PROTECTION  AGAINST  SMALL-POX.         223 

actly  that — neither  more  nor  less — which  an  attack  of 
small-pox,  either  taken  naturally  or  induced  by  a  com- 
pletely successful  inoculation,  would  confer  against  a 
subsequent  attack  of  the  same  disease.  Whatever 
phrase  may  be  picked  out  of  his  writings  here  and 
there  to  show  that  he  looked  on  the  security  which 
cow-pox  would  impart  against  small-pox  as  absolute,  that 
he  believed  that  the  human  system  which  had  once  felt 
genuine  cow-pox  was  "never  afterward,  at  any  period 
of  its  existence,  assailable  by  small-pox,"*  must  be 
read  with  this  limitation.  Any  other  reading  would 
be  quite  inconsistent  with  the  doctrine  he  invariably 
held  of  the  identity  of  cow-pox  and  human  small-pox. 
The  system  of  a  person  who  had  been  vaccinated  was 
regarded  by  him  as  having  already  passed  through 
small-pox.  and  as  being,  quoad  future  small-pox,  ex- 
actly in  the  condition  of  a  person  who  had  had  small- 
pox in  the  ordinary  way  (§  25).  And  as  he  was  well 
aware,  and  indeed  constantly  urged,  that  the  small-pox 
itself  did,  in  some  individuals,  recur,  and  that  the  hav- 
ing passed  through  one  attack,  was  not,  in  every  in- 
stance, a  security  against  a  future  attack,  so  he  looked 
for  similar  occurrences  after  vaccination.  What,  in 
short,  he  really  claimed  for  vaccination  is  thus  stated 
by  him :  "  Duly  and  efficiently  performed"  (for  this, 
of  course,  was  indispensable),  "  it  will  protect  the  con- 
stitution from  subsequent  attacks  of  small-pox  as  much 
as  that  disease  itself  will.  I  never  expected  it  would  . 
do  more  ;  and  it  will  not,  I  believe,  do  less."f 

*A  Continuation  of  Facts  and  Observations,  etc.,  by  E. 
Jenner,  M.D.     Lond.  1800. 

f  Baron's  Life  of  Jenner,  vol.  ii.  p.  135. 


224  HANDBOOK  OF   VACCINATION. 

86.  Small-pox  after  Natural  Small-pox. — That  small- 
pox may  occur  twice  in  the  same  individual  is  a  fact 
now  so  well  known,  and  so  universally  admitted,  that 
it  is  a  matter  of  some  astonishment  that  any  physicians 
should  have  ever  been  found  to  express  a  doubt  on  the 
subject.  There  have  been  those,  indeed,  who  denied 
altogether  the  possibility  of  it ;  but  generally  the  pos- 
sibility was  fully  allowed,  the  difference  of  opinion 
being  as  to  the  frequency  with  which  the  occurrence 
took  place.  On  this  point  medical  authorities  have 
been  most  divided.  While  Mead  and  others  looked  on 
a  recurrence  of  small-pox  as  of  the  utmost  rarity,  many 
physicians  regarded  it  as  by  no  means  extremely  in- 
frequent. Perhaps  the  discrepancy  is  not  wholly  inex- 
plicable. Those,  probably,  who  held  a  second  attack 
of  small-pox  to  be  so  extremely  rare,  did  not  consider 
any  attack  to  be  small-pox  which  had  not  the  full 
course  and  character  of  a  primary  attack.  Certain  it  is 
that  when,  soon  after  the  discovery  of  vaccination,  the 
modified  form  in  which  small-pox  occasionally  pre- 
sented itself  among  the  vaccinated  began  to  attract  at- 
tention, it  was  found  that  the  same  modifications  were 
also  sometimes  seen  in  persons  who  had  been  vario- 
lated. Further,  before  the  diagnostic  marks  of  variola- 
and  varicella  were  well  made  out  and  generally  recog- 
nized, there  was,  no  doubt,  much  mutual  confusion  ; 
and  as,  in  the  present  day,  wherever  the  distinction 
between  these  two  diseases  is  not  acknowledged  or  not 
well  attended  to,  cases  of  varicella  are  frequently  re- 
corded as  modifications  of  small-pox,  so,  conversely,  no 
doubt,  when  the  modifications  of  small-pox  were  little 
thought  of,  many  modified  secondary  cases  of  this  dis- 
ease might  be   ascribed  to  chicken-pox.      Except   on 


PROTECTION  AGAINST  SMALL-POX.         225 

some  such  grounds  as  these,  I  cannot  understand  how 
it  is  that  the  variolous  fever  without  eruption — the 
"  febris  variolosa" — seen  at  this  day,  so  far  as  I  know 
only  in  protected  persons',  should  nevertheless  be  so 
well  described  by  Sydenham,  who  appears  to  have  met 
with  many  cases  of  it,*  though  I  cannot  find  that  he 
refers  to  the  circumstance  whether  those  attacked  by 
it  had  had  small-pox  before  or  not. 

87.  Small-pox  after  Inoculated  Small-pox.  —  Al- 
though the  occurrence  of  secondary  small-pox  is  es- 
tablished by  numerous  writers  before  the  period  when 
inoculation  of  small-pox  was  first  introduced,  it  is  much 
more  frequently  referred  to  by  those  who  have  written 
since  that  date.  And  this,  indeed,  is  what  might  have 
been  anticipated,  for  it  seems  to  me  scarcely  to  be 
doubted  that  cases  of  small-pox  must  have  occurred 
with  greater  relative  frequency  among  individuals  to 
whom  small-pox  had  been  given,  or  was  believed  to 
have  been  given,  by  inoculation,  than  among  those  who 
had  had  the  disease  in  the  natural  way.  The  process 
of  variolous  inoculation  is  liable,  like  the  vaccine  pro- 
cess, to  accidental  disturbances  and  interferences  in  its 
course,  and  to  irregularities,  arising  cither  from  the 
state  of  the  matter  used,  or  from  the  state  of  the  child 
in  whom  it  was  inserted,  that  must  have  rendered  in- 
evitable, as  it  seems  to  me,  the  occasional  occurrence 
of  such  cases  as  the  following,  described  by  Mr.  Earle  : 
In  a  general  inoculation  he  had  made  in  the  village 
of  Arlingham,  in  1784,  he  had  inoculated  five  children 
with  variolous  matter  which  was  undoubtedly  genuine, 

*  Sydenham's  Works,  trans,  by  K.  G.  Latham,  vol.  i.  p. 
152,  seq. 

20 


226  HANDBOOK  OF   VACCINATION. 

though  it  had  been  taken  at  a  late  period  of  the  disease  ; 
infection  was  produced,  but  peculiarities  arose  in  the 
progress  of  the  cases  which  led  Mr.  Earle  to  consult  an 
elder  practitioner,  who,  however,  pronounced  the  chil- 
dren safe;  nevertheless,  four  out  of  the  five  children 
took  small-pox  afterward,  and  one  of  them  died ;  the 
only  one  who  escaped  an  attack  had  not,  at  the  time 
the  account  was  published,  been  exposed  to  infection. 
And  it  was  only  the  lesson  which  Mr.  Earle  had  learnt 
from  this  occurrence  that  made  him,  on  a  subsequent 
occasion,  test,  and  by  this  testing  inoculation,  save 
three  children  whose  inoculation  had  been  followed  by 
results  which,  to  most,  would  have  been  considered 
satisfactory.*  Other  writers  record  instances  in  which 
the  results  following  inoculation,  though  peculiar,  were 
yet  such  as,  according  to  the  highest  authorities  in 
inoculation,  justified  the  practitioner  in  pronouncing 
the  patients  safe,  and  yet  small-pox  was  subsequently 
taken, f  nor  were  cases  wanting  in  which  the  progress 
of  the  inoculation  so  closely  indeed  resembled  that 
which  was  normal  and  regular,  that  the  most  experi- 
enced could  not  distinguish  it,  but  in  which  the  process 
was  yet  unprotective,  true  natural  small-pox  manifest- 
ing itself  in  the  children  within  a  few  weeks  after  the 
phenomena  had  subsided.  J 

*  Jenner,  Further  Observations,  etc.,  4to.  1799. 

f  Kite,  Memoirs  of  Med.  Soc.  of  London,  iv.  114.  The  in- 
oculation took  local  effect  early,  and  ran  a  hastened  course,  the 
case  being  exactly  analogous  to  one  of  spurious  vaccination. 
But  Dimsdale,  who  was  familiar  with  cases  of  this  kind,  used 
to  regard  them  as  safe. 

%  Kite's  cases  showed  conclusively  that  this  might  occur 
where  the  inoculated  small-pox  had  gone  through  such  a 


PROTECTION  AGAINST  SMALL-POX.         227 

88.  Frequency  or  Infrequency  of  Recurrent  Small- 
pox.— Ploucquet  gives  a  list  of  seventy-four  writers 
who  record  cases  of  second,  and  some  of  them  even  of 
third,  or  of  several,  attacks  of  small-pox  in  the  same 
individual:*  Dr.  Hennen  gives  a  still  more  copious 
list  f  Half  a  century  and  more  ago,  when  small-pox 
was  much  more  common  than  now,  cases  were  cer- 
tainly Dot  rare.  Jenner  refers  to  the  very  large  num- 
ber of  which  there  were  authentic  accounts,  no  fewer 
than  seventeen  of  them  in  the  families  of  the  nobility.  J 
But  even  with  the  diminished  prevalence  of  small-pox 
since  that  period,  innumerable  cases  have  been  put  on 
record.  The  Provincial  Medical  and  Surgical  Asso- 
ciation collected,  in  1839,  from  various  correspondents, 

course  as  the  most  careful  and  experienced  practitioner  could 
not  distinguish  from  the  regular  course — the  local  phenomena 
heing  the  same,  the  fever  commencing  at  the  regular  period, 
and  continuing  the  normal  length  of  time,  and  the  eruption 
duly  following ;  the  only  possible  point  of  distinction  being 
that  most  of  the  pustules  did  not  completely  maturate — which, 
as  he  remarked,  is  repeatedly  the  case  in  the  real  small-pox 
when  the  eruption  has  been  moderate.  The  matter  used  in 
some  of  these  inoculations  had  been  taken  at  a  late  period  of 
the  pustule :  there  was  no  record  of  that  used  in  the  others. 
But  Mr.  Kite  speculates  whether  variolous  matter,  if  not  prop- 
erly taken,  or  if  not  properly  kept,  may  not  have  undergone, 
or  may  not  undergo,  changes  which  enable  it  to  produce  a 
certain  degree  of  variolous  infection,  but  not  enough  to  pro- 
duce the  disease  fully  and  completely.  A  similar,  most  inter- 
esting, question  arises  with  regard  to  the  effects  of  vaccination 
under  the  like  circumstances.  (See  p.  92,  note.) 

*  Literatura  Medica  Digesta,  tome  iv.  and  Supplement. 

f  Edin.  Med.  and  S.  Journal,  vol.  xiv.  p.  460. 

%  Baron's  Life  of  Jenner",  vol.  ii.  p.  159.  See  also  pp.  29 
and  303. 


228  HANDBOOK   OF   VACCINATION. 

239  such  cases;  and  in  the  inquiry  made  by  the  Epi- 
demiological Society  of  London,  in  1851,  which  has 
been  already  referred  to,  numerous  practitioners  re- 
ported cases  of  second  small-pox,  and  some  even  of 
third  attacks,  with  a  circumstantiality  of  detail  which 
left  no  ground  for  doubting  the  accuracy  of  the  state- 
ments. More  than  200  cases  of  second  small-pox  were 
thus  communicated,  the  evidence  of  the  primary  .attack 
being  generally  the  full  and  characteristic  marking  of 
the  patient,  and  the  second  attack  being  watched 
through  its  course  by  observers  whose  competence  to 
discriminate  accurately  could  in  most  instances  be 
relied  on.  In  the  official  inquiries  relative  to  small- 
pox which  I  have  been  called  on  to  make  since  1859, 
and  notably  during  the  recent  epidemic  (1863-6),  the 
occurrence  of  cases  of  second  small-pox  has  been 
brought  to  my  notice  on  numerous  occasions;  not  only 
in  most  of  the  large  towns  which  I  have  had  occasion 
to  visit,  but  also  in  small  towns  and  rural  districts. 
As  regards  many  of  these  cases  the  sufficiency  of  the 
evidence  was  quite  beyond  question :  one  or  two  of  them 
I  had  the  opportunity  of  seeing  in  progress,  and  in  sev- 
eral instances,  though  the  attack  was  over,  I  was  able 
to  examine  and  interrogate  those  who  had  suffered. 
Experience  abroad  coincides  with  experience  in  this 
country.  .  Haeser  states,  on  the  authority  of  Regoni- 
Stern,  that  at  Verona  in  the  ten  years  1829-38,  twenty- 
four  cases  of  second  small-pox  had  been  noted,  eight 
of  which  were  fatal  ;*  and  Heim  reports  in  the  epi- 
demics in  Wirtemberg,  1831-5,  fifty-seven  cases  of  re- 
current small-pox,  of  which  sixteen  died,  and,  in  sub- 

*  Haoser,  Die  Vaccination  und  ihre  neuesten  Gegner,  p.  52. 


PROTECTION  AGAINST  SMALL-POX.         229 

sequent  epidemics,  eighty-six  cases,  twelve  of  which 
were  fatal.* 

Data  do  not  exist  for  determining  in  what  propor- 
tion variolated  persons  may  afterward  take  small-pox. 
The  proportion  will  no  doubt  be  affected  by  the  same 
circumstances  as  will  hereafter  be  referred  to  (§  92)  as 
influencing  the  extent  to  which  small-pox  may  be  taken 
after  vaccination,  especially  by  the  presence  of  epidemic 
influence  The  calculation  which  was  made  by  the 
Societe  de  Medecine  of  Marseilles,  that  one  per  cent, 
of  the  variolated  portion  of  the  population  of  that  town 
suffered  from  second  small-pox  during  the  epidemic 
that  prevailed  there  in  1828,f  can  only  be  taken  as  a 
very  rough  approximation.  All  that  is  certain  is,  that 
twenty  cases  of  second  small-pox,  or  what  was  held  to 
be  second  small-pox,  were  noted  during  a  part  only  of 
that  outbreak.  Other  observations  which  have  more 
numerical  precision  have  been  made  on  special  classes 
of  the  community.  Thus,  of  the  1950  boys  admitted 
into  the  Royal  Military  Asylum,  Chelsea,  between  the 
years  1803  and  1831,  who,  at  the  time  of  their  admis- 
sion, were  recorded  as  having  marks  of  small-pox, 
twelve  (or  615  per  thousand)  contracted  small-pox 
during  the  period  of  their  residence  at  the  Asylum.  J 

*  Heim,  as  quoted  by  Simon,  Papers  relating,  etc.  (op.  cit.), 
pp.  xxvii.  and  xxxv. 

f  Bousquet,  Nouveau  Traite",  etc.,  p.  269. 

%  It  is  just  possible  that  in  some  of  these  cases  the  marks 
which  the  children  exhibited  on  their  admission  might  be 
marks  of  chicken-pox.  The  distinction  between  such  marks 
and  the  marks  left  by  small-pox,  when  these  are  few  and  scat- 
tered, as  they  would  generally  be  in  cases  of  the  inoculated 
disease,  is  not  always  easy,  nor  even  always  possible :  and  a 
20* 


230  HANDBOOK  OF   VACCINATION. 

In  answer  to  some  inquiries  which  were  made  by  the 
Epidemiological  Society  of  London,  in  1851,  of  various 
medical  practitioners  in  the  United  Kingdom,  as  to 
their  personal  protection  against  small-pox,  thirty-two 
who  had  had  natural  small-pox  when  young  had  none 
of  them  suffered  from  any  second  attack,  but  of  ninety- 
five  who  had  been  inoculated,  and  were  considered  to 
be  safe,  three  had  since  contracted  small-pox:  and  in 
reply  to  a  further  set  of  inquiries  on  this  subject,  after- 
ward more  extensively  distributed  by  the  society,  fifty- 
four  practitioners  stated  that  they  had  had  natural 
small-pox  in  childhood,  of  whom  one  had  suffered  from 
a  second  attack;  two,  who  had  been  vaccinated  in 
childhood,  had  since  had  small-pox  more  than  once;  of 
five  who  had  had  small-pox  in  childhood,  either  natu- 
rally or  by  inoculation,  but  did  not  state  which,  none 
had  since  had  small-p6x;  and  of  219  who  had  been  in- 
oculated successfully,  seven  answered  distinctly  that 
they  had  had  small-pox  at  a  subsequent  period  of  their 
lives,  and  six  more  stated  that  they  had  had  small-pox, 
but  the  wording  of  the  answer  was  so  ambiguous  that 
it  was  not  certain  whether  the  attack  referred  to  was 
that  which  resulted  from  the  inoculation  or  was  of  sub- 
sequent and  independent  occurrence.*  These  facts,  so 
far  as  they  go,  tend  to  the  conclusion  that  natural 
small-pox  is  more  protective  against  a  second  attack 
than  the  inoculated  form  of  the  disease.  And  it  is 
quite  possible  that,  now  that  the  practice  of  inoculation 

knowledge  of  the  history  and  circumstances  of  the  first  attack 
is  often  necessary  to  make  the  diagnosis  sure. 

*  Further  inquiries  were  made  on  this  point,  but  the  neces- 
sary information  not  elicited. 


PROTECTION  AGAINST  SMALL-POX.         231 

has  been  so  long  forbidden  by  law,  and  so  long  discon- 
tinued, cases  of  second  small-pox  will  be  less  common 
than  they  were  during  the  latter  part  of  the  last  and 
the  earlier  part  of  the  present  century.  Marson  regards 
second  small-pox  as  very  rare — more  rare  than  my  own 
observations,  or  my  own  inquiries  among  my  profes- 
sional brethren,  or  the  facts  above  cited  would  lead  me 
to  consider  it.  Still,  one  per  cent,  of  all  the  admissions 
into  the  Small-pox  Hospital  are  cases  of  second  attacks 
of  the  disease.  In  the  Annual  Medical  Reports  of  the 
Army  and  Navy  many  indisputable  cases  of  second 
small-pox  will  be  found :  among  the  small  proportion 
of  the  troops  serving  in  the  United  Kingdom  whose 
protection  against  small-pox  was  the  having  already 
had  that  disease,  three  such  cases  occurred  in  the  six 
years,  1859-64.* 

89.  Small-pox  after  Vaccination. — The  lapse  of  a  few 
years  from  the  promulgation  of  Jenner's  discovery  was 
enough  to  bring  to  light  cases  in  which  vaccination 
failed  to  give  complete  immunity  from  small-pox.  As 
early  as  1806,  the  Medical  Council  of  the  Royal  Jenne- 
rian  Institution  stated  that  a  few  cases  had  been  brought 
to  their  notice  of  persons  having  the  small-pox,  though 
generally  of  a  mild  description,  who  had  apparently 
passed  through  the  cow-pox  in  a  regular  way  ;f  and  in 

*  The  proportion  of  recruits  who  are  protected  hy  variola 
is  now  about  one-eleventh  ;  but  some  years  ago,  from  1846-55, 
it  exceeded  one-fifth.  I  apprehend  that  scarcely  any  of  the 
troops  now  serving  can  have  had  the  inoculated  form  of  variola. 

f  Papers  relating  to  the  History  and  Practice  of  Vaccina- 
tion, p.  5.  The  Council  states  also  "  that  cases,  supported  by 
evidence  equally  strong,  have  also  been  brought  before  them, 
of  persons  who  after  having  once  regularly  passed  through  the 


232  HANDBOOK  OF   VACCINATION. 

the  same  year  Willan  recorded,  in  his  most  interesting 
and  useful  treatise  "On  Vaccine  Inoculation,"  various 
cases  in  which  a  very  trivial  eruption,  but  of  true 
variolous  character,  appeared,  in  children  who  had  been 
vaccinated,  at  intervals  which  had  varied  from  five 
months  to  seven  years  after  the  performance  of  the 
vaccination.  The  singular  modification  which  the 
small-pox  underwent,  and  the  harmless  and  insignifi- 
cant character  it  usually  assumed,  in  those  protected 
by  vaccination — thus  early  noted — attracted  much  more 
attention  when,  in  the  great  epidemic  of  small-pox 
which  prevailed  in  18 17  and  the  years  immediately  fol- 
lowing, cases  of  post-vaccinal  small-pox  became  more 
common.  It  was  then  remarked,  and  the  observation 
has  been  confirmed  by  the  experience  of  all  subsequent 
epidemics,  that  though  some  vaccinated  persons  may 
contract  small-pox  at  an  early  period  after  vaccination 
— even,  as  Willan  showed,  within  a  few  weeks  or 
months — post-vaccinal  small-pox  was  met  with  in  much 
larger  proportion  among  those  who  are  grown  up ;  and 
that  it  was  exclusively  among  these  latter  that  it  as- 
sumed (and  even  among  them  in  only  a  relatively  small 
proportion  of  cases)  a  serious,  and  especially  a  fatal, 
character.  Many  cases  of  the  small-pox  which  mani- 
fested itself  in  those  who  had  been  vaccinated  were 
clearly  assignable  to  imperfect  vaccination,  but  in 
others  the  vaccination  appeared  to  have  been  regular 
and  complete.     The  difference  in  its  symptoms  and 

small-pox,  either  by  inoculation  or  natural  infection,  have 
had  that  disease  a  second  time."  This  interesting  report 
(signed,  among  others,  by  Lettsom,  Bahington,  Denman, 
and  Baillie)  is  well  worth  perusal. 


PROTECTION  AGAINST  SMALL-POX.         233 

course  which  the  small-pox  assumed  in  those  who  had 
been  vaccinated  was  so  striking,  that  the  late  Dr.  John 
Thomson  of  Edinburgh  was  induced  to  propose  for  this 
form  of  the  disease  a  distinguishing  name,  calling  it 
"varioloid."  The  name,  as  Marson  justly  observes, 
though  it  has  been  very  extensively  adopted,  is  ill 
chosen :  "  The  disease  is  not  simply  'like'  small-pox,  as 
the  name  implies;  it  is  small-pox;  it  will  give  the  dis- 
ease in  the  most  severe  form,  in  the  natural  way,  by 
infection,  to  the  unvaccinated,  and  will  produce  small- 
pox by  inoculation  just  as  a  case  of  small-pox  unin- 
fluenced by  vaccination  will  do."*  The  term  "modi- 
fied small-pox,"  which  Marson  proposes  to  apply  to  all 
the  post-vaccinal  cases  which  exhibit  the  characteristic 
modification,  is  very  much  better,  and  will,  I  trust, 
wholly  supersede  it. 

90.  Modes  in  which  the  Power  of  Vaccination  over 
Small-pox  is  manifested. — It  is  not  solely  then  in  the 
way  that  Jenner  appears  to  have  first  anticipated, 
that  the  benefits  of  his  immortal  discovery  are  felt  by 
mankind.  Nearly  seventy  years'  use  of  vaccination 
has  proved  beyond  doubt  that,  "duly  and  efficiently 
performed,"  its  power  of  influencing  small-pox  is  indeed 
almost  absolute, — but  that  it  acts,  not  invariably  by 
preventing,  but  sometimes  only  by  controlling  that 
disease.  The  vast  majority  of  those  who  have  gone 
regularly  through  the  vaccine  process  are  saved  thereby 
from  any  future  attack,  however  modified  or  slight,  of 
small-pox.  In  the  minority,  who  have  not  been  ren- 
dered by  it  completely  proof  against  the  influence  of 

*Art.  "Small-pox,"  System  of  Medicine  (op.  cit),  vol.  i. 
p.  472. 


234  HANDBOOK  OF   VACCINATION. 

the  small-pox  poison,  the  action  of  that  virus  on  the 
economy  is  yet  so  modified  by  it  that  the  small-pox,  as 
a  rule,  is  deprived  of  all  danger  to  life,  and  does  not 
leave  behind  it  those  disfiguring  traces  which  are  not 
the  least  of  the  terrors  of  unmodified  variola. 

(a)  By  conferring  on  the  large  majority  of  the  Vac- 
cinated complete  immunity  from  that  disease. — There 
is  certainly  no  subject  on  which  medical  testimony  is 
more  unanimous  than  on  the  very  large  immunity  from 
attacks  of  small-pox  which  successful  vaccination  will 
confer.  While  there  are  exceedingly  few  unvaccinated 
persons  who  reach  the  average  duration  of  human  life 
without  having  sustained  an  attack  of  variola,  and 
while  the  very  great  majority  of  such  persons  are  at- 
tacked by  it  in  childhood,  the  vaccinated  are,  as  a  rule, 
entirely  exempt  from  that  disease.  The  first  question, 
says  that  distinguished  medical  philosopher  Dr.  Ali- 
son, which  we  have  to  consider,  is  "whether  or  not  we 
have  at  this  time,  in  the  matter  of  cow-pox,  a  power  at 
our  command  capable,  if  duly  employed,  of  depriving 
the  poison  of  small-pox  of  all  fatal  influence  over  an 
immense  majority  of  mankind.  And  on  this  subject 
there  has  been  quite  sufficient  information  collected, 
since  the  date  of  the  papers  which  were  held  decisive 
of  the  question  fifty  years  ago,  to  show  that  the  same 
inference  is  still  inevitable,  and  that  he  who  disputes 
it  is  equally  unreasonable  as  he  who  opposes,  in  like 
manner,  any  proposition  in  Euclid.  Of  course,  when 
I  say  that  there  has  been  ample  evidence  to  decide  this 
question  statistically,  I  mean  to  refer  to  cases  where 
we  have  not  only  the  negative  evidence  of  large  num- 
bers of  persons  duly  vaccinated  not  having  subsequently 
been  affected  with  small-pox,  but  the  positive  evidence 


PROTECTION  AGAINST  SMALL-rOX.         235 

of  such  duly  vaccinated  persons  having  been  subse- 
quently, most  of  them  repeatedly,  or  for  a  long  time 
together,  exposed  to  the  contagion  of  small-pox,  i.e. 
placed  in  the  same  circumstances  in  which  unvac- 
cinated  people  have  been  very  generally  affected,  and 
many  of  them  died  of  the  small-pox;  these  vaccinated 
persons  have  nevertheless  escaped,  most  of  them  with- 
out any  indication  of  disease.  To  show  that  this  is 
the  light  in  which  I  have  always  regarded  such  col- 
lections of  facts,  I  quote  one  sentence  from  my  own 
lectures,  written  as  long  ago  as  1820-21,  and  repeated 
almost  every  winter  since  then:  'You  will  remember 
that  the  question  is,  not  how  many  vaccinated  persons 
never  take  small-pox,  but  how  many  vaccinated  persons 
are  fully  exposed  to  the  contagion  of  small-pox  and 
escape  without  any  disease;  and  our  assertion  is,  that, 
so  far  as  is  yet  known,  absolute  protection  of  the  human 
constitution  is  the  rule,  and  the  occurrence  of  any  dis- 
ease is  the  exception.'"*  A  vast  body  of  evidence 
which  was  collected  by  the  Epidemiological  Society,  in 
1851-2,  from  all  parts  of  the  kingdom  and  from  abroad, 
fulfilled  exactly  the  conditions  which  Dr.  Alison  has  so 
justly  pointed  out  as  essential  for  proof, — evidence  of 
vaccinated  persons  (children  or  grown  up)  living  in 
crowded  and  ill-ventilated  dwellings  in  which  the  small- 
pox infection  was,  occupying  the  same  rooms,  and  sleep- 
ing in  the  same  beds  with  small-pox  cases,  mothers 
nursing  their  babies  who  were  suffering  from  the  dis- 
ease,— all  placed  in  circumstances  in  which  no  un vac- 
cinated or  otherwise  unprotected  person,  or  scarcely 
any  such,  escaped,  and  yet  themselves  remaining  en- 

*  Papers  relating  to  the  History,  etc.,  p.  119. 


23 fi  HANDBOOK  OF   VACCINATION. 

tirely  unscathed.  One  of  the  most  striking  proofs  of 
the  protective  power  of  vaccination  is  that  which  has 
been  repeatedly  afforded  by  cases  in  which  pregnant 
vaccinated  women  were  the  means  of  passively  con- 
veying the  variolous  infection  to  the  foetus  in  utoro, 
themselves  remaining  entirely  unaffected  by  it.*  But 
this  general  immunity  of  the  vaccinated  from  small- 
pox is  such  an  established  and  admitted  fact,  that  in  a 
professional  work  it  would  be  idle  to  dwell  upon  it  any 
longer. 

(b)  By  modifying  the  course  of  Small-pox,  or  other- 
wise diminishing  its  danger,  in  those  in  whom  the 
protection  has  not  been  absolute. —  The  modifying 
power  of  vaccination — its  power  of  so  altering  the 
course  and  character  of  small-pox  as  to  concert  it  from 
a  disease  usually  severe,  confluent,  and  in  a  large  pro- 
portion of  cases  fatal,  into  a  disease  for  the  most  part 
slight,  unimportant,  and  void  of  danger — is  equally 
well  established.  The  degrees  in  which  small-pox  may 
be  modified  by  vaccination  are  various,  depending  on 
various  circumstances,  but  chiefly,  as  we  shall  see  pres- 
ently, on  the  way  in  which  the  vaccination  has  been 
done.  There  may  be  absolutely  no  eruption  at  all,  the 
disease  being  cut  short  in  the  stage  of  primary  fever — 
"febris  variolosa;"  or  there  maybe  a  mere  efflorescence, 
without  papulation  or  vesiculation;  or  there  may  be  a 
few  scattered  vesicles ;  or  a  full  discrete  eruption  which 
is  semi-confluent  or  confluent,  but  yet  which  is  modified 

*  See  a  Paper  by  Jenner  in  Medico-Chir.  Trans.,  vol.  i.; 
Rapport  de  l'Acad.  Roy.  de  Medecine,  1842;  ibid.  1846.  Some 
cases  of  this  kind  were  communicated  to  the  Small-pox  Com- 
mittee of  the  Epidemiological  Society.  The  same  occurrence 
has  been  noted  in  women  protected  by  having  had  small-pox. 


PROTECTION  AGAINST  SMALL-POX. 


23 1 


in  its  course.  Modification,  indeed,  does  not  occur  in 
all  cases  of  post-vaccinal  small-pox:  in  some,  particu- 
larly where  the  vaccination  has  been  imperfect,  the 
small-pox  is  observed  to  run  its  usual  course.  The 
following  table  will  show  in  what  proportion  cases  of 
post-vaccinal  small-pox  were  found  to  be  modified  or 
unmodified,  in  the  practice  of  the  Small-pox  Hospital 
of  London  from  1836  to  1851  inclusive,  as  compared 
with  the  disease  when  it  occurred  in  unprotected  per- 
sons: 


Per  100  Patients  of 

each  class 

respectively. 

Eruption  of  Small-pox 
unmodified. 

Eruption  of  Small-pox 
modified. 

a 

■ 

9 

<a 

a 

a 

=    . 
o  *> 

at 

a 

5 

6-3 
3-2 

"3 
o 
H 

a 
0 
m 
a 

a 

a   . 
o  - 
o  a 
J-  - 

h 

J 

.5.2 
.s  = 

"3 
1 

68-6 
15-3 

22-5 
8-3 

97-4 
26-8 

0-635 
17-5 

0-635 
15-0 

1-32 
40-5 

2-6 
730 

Vaccinated    with 

But  even  in  a  large  proportion  of  the  cases  in  which 
the  course  of  the  eruption  was  apparently  unmodified 
by  the  vaccination,  the  controlling  power  of  that  pro- 
cess (imperfect  as  the  vaccination  had  in  most  instances 
been)  still  manifested  itself  in  the  death-rate,  which  in 
the  unmodified  natural  cases  was  very  nearly  the  dou- 
ble of  what  it  was  in  the  unmodified  post-vaccinal 
cases  (38  per  cent,  of  attacks,  as  compared  with  21 
per  cent.).  In  the  modified  cases,  the  death-rate 
scarcely  exceeded  1$  per  cent.  Hence,  when  the  total 
mortality  arising  from  small-pox  in  the  hospital  in  the 
patients  who  were  unprotected  was  compared  with  the 
total  mortality  of  the  disease  in  those  patients  who 

21 


238  HANDBOOK  OF   VACCINATION. 

had  any  mark  of  vaccination  (all  cases  of  superadded 
disease  being  deducted  from  either  of  the  two  classes), 
it  was  found  that  in  the  former  it  was  nearly  seven 
times  as  great  as  in  the  latter,  that  the  death-rate  of 
natural  small-pox  was  in  fact  3555  per  cent,  of  the 
cases,  while  the  death-rate  of  post-vaccinal  small-pox. 
was  but  525  per  cent.*  A  similar  difference  is  met 
wi  h  whenever  and  wherever  small-pox  prevails. 
While,  as  has  been  before  stated  (§  81)  the  mortality 
of  natural  small-pox  is  seldom  below  20  per  cent,  and 
often  greatly  exceeds  that  rate,f  post-vaccinal  small- 
pox, as  recorded  by  observers  who  have  been  careful 
no  to  include  cases  of  varicella,  is  fatal  in  proportions 
varying  from  3  to  5  and  6  per  cent.  only.J  Not  to 
dwell  on  a  point  which  really  does  not  admit  of  dis- 
pute, and  which  will  besides  be  abundantly  illustrated 
in  the  course  of  this  chapter,  it  will  be  sufficient  here 
to  state  that,  of  658  cases  of  post-vaccinal  small-pox 

*  Marson  in  Medico-Chir.  Trans.,  vol.  xxxvi. 

|  E.g.  in  the  Edinburgh  epidemic  (1818-19),  24-3  per  cent.; 
in  an  epidemic  at  Chelsea  (1838-9),  27-9  per  cent.;  in  one  at 
"Wandsworth  (1844-5),  27-5  per  cent.;  in  five  epidemics  at 
Copenhagen  (1824-35),  25-7  per  cent.;  in  the  practice  of  the 
Gh.sgow  Infirmary,  31-7  per  cent.  (Seaton,  Protective  Power 
of  Yaccin.,  etc.,  Sanitary  Review,  vol.  ii.  p.  354.) 

\  The  returns  to  the  Epidemiological  Society,  when  summed 
up.  gave  the  death-rate  of  post-vaccinal  small-pox  as  about  3 
(2-'J)  per  cent.,  and  many  of  the  deaths  on  which  this  rate  was 
calculated  were  not  really  from  small-pox,  but  from  super- 
added disease.  But  these  returns  included  a  number  of  cases 
of  she  post-vaccinal  small-pox  of  childhood  (almost  always  a 
trivial  affection).  In  comparing  the  records  of  different  ob- 
ser/ers  with  regard  to  the  fatality  of  post-vaccinal  small-pox, 
this  is  a  point  that  must  not  be  overlooked. 


PROTECTION  AGAINST  SMALL-POX.         239 

which  occurred  during  the  six  years  1859-65,  among 
the  troops  stationed  in  the  United  Kingdom,  thirty- 
eight  only,  or  5-8  per  cent.,  were  fatal ;  and  that,  in 
observations  which  have  particular  value  on  account 
of  the  large  scale  on  which  they  were  made — viz.  those 
made  for  twenty-one  years  in  Bohemia,  on  four  mil- 
lions of  people — the  death-rate  among  vaccinated  per- 
sons who  happened  to  contract  small-pox  was  found  to 
be  but  5T'g  per  cent.,  wh:le  the  death-rate  from  the 
same  disease  in  persons  who  were  unprotected  was 
29 1  per  cent. 

91.  Testimony  of  the  Medical  Profession  as  to  the 
Protective  Power  of  Vaccination. — The  Epidemio- 
logical Society,  in  the  course  of  the  inquiry  it  instituted, 
in  1851-2,  into  the  state  of  small-pox  and  vaccination 
in  England,  elicited  from  nearly  2000  medical  practi- 
tioners the  results  of  their  experience  as  to  the  protec- 
tive value  of  vaccination.  Various  differences  of  0] tin- 
ion  were  expressed  by  these  correspondents  with  regard 
to  the  exact  extent  to  which,  and  the  time  during 
which,  the  successful  vaccination  of  a  person  was  pro- 
tective against  small-pox,  some  holding  this  protection 
to  be  much  more  absolute  and  durable  than  others  did ; 
but  there  was  the  utmost  unanimity  of  expression  re- 
specting the  existence  of  the  protective  power,  and 
there  was  not  a  single  practitioner  who  did  not  look 
on  vaccination  as  a  practice  which  ought  to  be  univer- 
sally adopted.  And  when,  some  years  later,  the  Medi- 
cal Officer  of  the  then  Board  of  Health  (now  the  Medical 
Officer  of  the  Privy  Council)  addressed  to  distinguished 
members  of  the  medical  profession,  at  home  and  abrcad, 
the  question,  "  Have  you  any  doubt  that  successful 
vaccination  confers  on  persons  subject  to  its  influence 


240  HANDBOOK  OF   VACCINATION. 

a  very  large  exemption  from  attacks  of  small-pox,  and 
almost  absolute  security  against  death  by  that  dis- 
ease ?" — of  542  respondents,  only  two  expressed  any 
doubt  whatever.* 

92.  Circumstances  which  influence  the  Protective 
Power  of  Vaccination. — Various  circumstances  exer- 
cise more  or  less  of  influence  on  the  protective  power 
of  vaccination.  The  principal  of  these  are  (a)  the 
quality  of  the  vaccination,  (b)  the  age  of  the  individual, 
(c)  personal,  hereditary,  or  family  susceptibility,  (d) 
change  of  climate,  (e)  frequency  and  extent  of  expo- 
sure to  infection,  (/)  intensity  of  epidemic  influence. 
Each  of  these  demands  separate  consideration. 

(a)  Quality  of  the  Vaccination. — It  need,  one  would 
suppose,  scarcely  be  said  that  no  case  of  small-pox 
should  ever  be  recorded  as  post-vaccinal,  until-the  prac- 
titioner has  taken  care  to  ascertain  that  the  vaccination 
has  been  an  effectual  one.  My  experience,  however, 
shows  me  that  this  care  is  by  no  means  always  taken. 
I  have  repeatedly  known  cases  of  small-pox  put  down 
as  post-vaccinal  on  the  mere  statement  of  the  parents 
or  the  patients  that  "  they  had  been  vaccinated,"  with- 
out any  inquiry  being  made  as  to  the  results  of  the 
operation — cases   in   which   a   few   questions,    subse- 

*  One  of  these  gentlemen  distrusted  vaccination,  and 
"would  gladly  inoculate  his  own  children  with  small-pox;" 
according  to  the  other,  the  eccentric  Dr.  Hamernik,  of  Prague, 
neither  cow-pox  nor  small-pox,  when  once  passed  away,  has 
any  influence  on  future  events ;  and  a  person  who  has  had 
small-pox  itself  is  no  more  protected  thereby  against  future 
attacks  than  he  would  have  been  by,  say,  an  attack  of  measles ! 
(Preface  to  Papers  relating  to  the  History,  etc.,  p.  lxxx.,  and 
Papers,  p.  127,  seq.) 


PROTECTION  AGAWST  SMALL-POX.         241 

quently  put,  elicited  at  once  that  the  vaccination  had 
not  taken  effect  at  all.  The  terms  "vaccination  "  and 
"  vaccinated,"  as  popularly  used,  so  frequently  refer  to 
the  mere  performance  of  the  operation  irrespective  of 
its  results,*  that,  in  any  case  of  small-pox  in  a  child  or 
other  person  said  to  have  been  vaccinated,  the  practi- 
tioner should  never  omit  (1)  to  get  the  best  information 
he  can  as  to  what  the  immediate  results  of  the  opera- 
tion were,  and  (2)  to  examine  for  himself  the  character 
and  the  number  of  the  cicatrices.  The  typical  char- 
acter of  the  cicatrix  is  our  best  available  test,  and  it  is 
a  most  reliable  one,  of  the  vaccination  having  been 
genuine  and  perfect. f 

In  order  that  persons  should  have  from  vaccination 
the  fullest  protection  against  small-pox  which  it  is  ca- 
pable of  imparting,  it  is  necessary  that  the  vaccination 

*  This  is  one  of  the  reasons  of  the  erroneous  entries  respect- 
ing vaccination  frequently  occurring  in  the  Death-Registers  ; 
see  postea  (p.  251,  note);  see  also  ante  (p.  122,  and  note)  as 
to  another  source  of  error,  and  the  points  for  inquiry  when 
the  alleged  vaccination  has  been  of  recent  occurrence. 

f  Foveated  cicatrices,  closely  or  exactly  resembling  the  vac- 
cine, may  occasionally  arise  from  other  causes  than  vaccina- 
tion ;  but  it  is  rare  indeed  for  them  to  be  seen  on  the  spots  on 
which  vaccination  would  have  been  performed,  unless  as  the 
result  of  that  process;  and  though,  in  above  100,000  ob- 
servations, I  have  met  with  here  and  there  a  case  in  which, 
on  superficial  examination,  I  might  have  hesitated,  I  do  not 
remember  one  in  which,  by  a  little  attention,  I  was  not  able 
to  discriminate.  On  the  other  hand,  cases  are  more  frequent 
in  which,  though  the  vaccination  has  gone  through  a  com- 
plete and  satisfactory  course,  the  cicatrices  left  are,  after  a 
time,  indistinct  or  imperfect.  But  these  cases  are  still  quite 
the  exception,  and  do  not  affect  the  validity  of  the  rule  laid 
down  in  the  text. 

21* 


242  HANDBOOK  OF   VACCINATION. 

should  not  only  be  perfect  in  character,  but  that  it 
should  be  sufficient  in  amount — that  the  system  should 
not  only  be  infected,  but  that  it  should  be  well  infected. 
By  observations,  of  unsurpassable  interest  and  value, 
made  for  upwards  of  thirty  years  at  the  Small-pox 
Hospital,  it  has  been  demonstrated  that  the  extent  to 
which  small-pox,  if  it  should  be  contracted  at  all  after 
vaccination,  is  modified  by  the  vaccination,  is  determ- 
ined by  the  character  and  number  of  the  cicatrices ; 
that  it  is  in  the  exact  ratio  of  the  excellence  and  com- 
pleteness of  the  vaccination,  as  determined  by  these 
tests.  Persons  whose  vaccination  has  resulted  in  their 
having  one  genuine  vaccine  vesicle,  and  one  only,  are, 
as  a  class,  much  less  protected  than  those  who  have 
had  two,  those  who  have  had  two  than  those  who  have 
had  three,  etc.;  and  the  protection  against  fatal  small- 
pox which  is  afforded  by  four  or  more  genuine  vesicles 
is  almost  absolute.  The  subjoined  table,  giving  the 
results  of  Marson's  observations  on  nearly  5000  post- 
vaccinal cases  which  occurred  in  the  twenty  years  from 
1836  to  1855  inclusive,  will  show,  at  a  glance,  the  in- 
fluence exercised  on  the  course  of  small-pox  by  the 
character  and  number  of  the  vaccine  marks  :* 

Classification  of  Patients  Number  of  Deaths 

affected  with  Small-pox.  per  cent,  in  each 

class  respectively. 

1.  Unvaccinated 35 

2.  Stated  to  have  been  vaccinated,  but  having 

no  cicatrix 23-57 

*  Art.  "Small-pox,"  in  System  of  Medicine,  ed.  by  J.  R. 
Reynolds,  M.D.,  vol.  i.  pp.  448  and  473.  The  death-rate 
among  those  having  previously  had  small-pox  is  not  given  in 
this  Article,  but  is  taken  from  Marson's  Paper  in  Medico- 
Chir.  Trans.,  vol.  xxxvi. 


PROTECTION  AGAINST  SMALL-POJT.         243 

3.  Vaccinated — 

a.  Having  one  vaccine  cicatrix 7-73 

b.  Having  two  vaccine  cicatrices 4-70 

c.  Having  three  vaccine  cicatrices 1*95 

d.  Having  four  or  more  vaccine  cicatrices  055 

a.  Having  well-marked  cicatrices 2-52 

/3.  Having  badly-marked  cicatrices 8-82 

4.  Having  previously  had  small-pox 19 

It  is  in  the  classes  which  had  only  one  or  two  cica- 
trices that  the  influence  of  character  of  the  cicatrix 
was  most  remarkably  seen.  In  those  who  had  one 
cicatrix  only,  if  this  cicatrix  were  thoroughly  well 
marked,  the  death-rate  per  cent,  was  3  83;  but  among 
cases  in  which  the  single  cicatrix  was  badly  marked, 
the  death-rate  was  11*91  per  cent.  And  while  among 
cases  which  had  two  well-marked  cicatrices  the  death- 
rate  per  cent,  was  2  32,  among  cases  which  had  two 
badly-marked  cicatrices  the  rate  was  8  34. 

It  is  probable  that  a  modification  of  Marson's  observ- 
ations which  should  have  taken  into  account  the  area, 
as  well  as  the  number  of  the  cicatrices,  would  have 
told  still  more  for  character  as  distinguished  from  mere 
number  of  marks.  No  size  of  cicatrix  will  convert  a 
bad  one  into  a  good  one,  nor  is  any  kind  of  mark  to  be 
more  distrusted  than  a  large  one,  if  it  be  smooth  and 
irregular :  but,  on  the  other  hand,  it  is  impossible  that 
two  cicatrices  of  typical  character 
like  these  should  represent  the  /*^Tt\  /*»*»/*>\ 
same  amount  of  local  effect,  or  \^f¥)  [#Y/*j>'*l 
that  it  can  make  any  difference  \5/  V^VV 
whether  the  two  or  three  vesicles  ^■""^ 

which  must  have  combined  to  produce  the  larger  of 
these  marks,  should  have  been  produced  together  on 
one  spot  of  the  skin,  or  singly  on  two  spots. 


244  HANDBOOK  OF   VACCINATION. 

Recurring,  however,  to  Marson's  observations  as 
they  stand,  we  see  at  once  that  the  statement  pre- 
viously made,  that  in  the  Small-pox  Hospital  post- 
vaccinal small-pox  was  fatal  in  from  five  to  six  per 
cent,  of  the  cases  that  occurred,  requires  a  great  deal 
of  qualification.  It  is  true  in  the  gross,  if  we  take 
good  and  bad  vaccination  together,  but  in  the  gross 
only.  It  represents  much  too  favorably  the  results  of 
bad  vaccination,  and  much  too  unfavorably  the  results 
of  good  vaccination.  Let  an  unvaccinated  person  con- 
tract small-pox,  and  the  chances  are  more  than  one  in 
three  that  he  dies  ;  let  a  very  badly  vaccinated  person 
(a  person  with  one  imperfect  cicatrix)  contract  small- 
pox, and  the  chances  are  not  quite  one  in  eight  that  he 
dies ;  let  a  person  with  two  good  vaccine  cicatrices 
have  small-pox,  and  his  chances  of  dying  are  less  than 
one  in  forty  ;  but  persons  who  have  been  vaccinated 
in  the  best  and  most  complete  way  will,  if  they  ever 
get  small-pox  afterward,  not  die  of  it  at  the  rate  of 
much  more  than  one  in  two  hundred.  The  small-pox 
death-risks  of  no-vaccination  are  to  the  death-risks 
of  the  very  worst  vaccination  as  three  to  one,  to  the 
death-risks  of  the  best  vaccination  as  seventy  to  one ; 
and  a  well-vaccinated  person  has  not  one-twentieth 
part  the  risk  of  dying  of  small-pox  that  a  badly  vac- 
cinated person  has.  Nor  is  the  death-risk  the  only 
thing  to  be  taken  into  account  in  estimating  the  differ- 
ence between  good  and  bad  vaccination  ;  there  is  also 
to  be  considered  the  difference  in  the  amount  of  suffer- 
ing and  in  the  risk  of  disfigurement. 

"Small-pox  after  vaccination,"  says  Marson,  "has, 
in  fact,  various  degrees  of  severity  and  modification: 
from  the  slightest  form,  in  which  there  is  none,  or 


PROTECTION  AGAINST  SMALL-POX.         245 

hardly  any  eruption  at  all,  to  the  most  severe  conflu- 
ent cases,  closely,  almost  exactly,  resembling  the  dis- 
ease in  the  unvaccinated ;  and  it  also  assumes  the  pe- 
techial and  malignant  types  after  vaccination,  just  as 
in  the  unvaccinated  state.  All  this  depends  in  a  great 
measure  on  the  way  in  which  patients  have  been  vac- 
cinated. Those  who  have  been  fortunate  enough  to 
have  been  vaccinated  in  four  or  more  places  with 
lymph  that  leaves  good,  easily  perceptible  cicatrices, 
have  almost  invariably  a  slight  form  of  small-pox  when 
it  occurs;  but  those  who  have  only  one  or  two  marks 
from  vaccination,  such  as  are  hardly  visible,  will  prob- 
ably have  a  severe  form  of  the  disease ;  and  those  who 
have  no  marks  at  all  are  in  still  worse  circumstances. 
Now,  although  this  rule  holds  good  generally,  almost 
invariably,  still  it  is  not  an  invariable  rule;  and  per- 
haps more  exceptions  will  be  found — we  may  say,  will 
certainly  be  found — in  those  who  have  been  indiffer- 
ently vaccinated,  than  in  those  who  have  been  well 
vaccinated.  Persons  seemingly  indifferently  vaccinated 
will  oftener  afterward  have  a  light  form  of  small-pox 
than  well-vaccinated  persons  will  have  a  severe  form 
of  the  disease.  So  far  it  is  fortunate.  But  what  we 
contend  for,  and  always  have  contended  for,  is  that,  if 
possible,  all  should  be  vaccinated  in  the  best  way ;  at 
least  the  attempt  should  be  made  to  vaccinate  all  in 
the  best  way,  that  there  should  be  as  little  as  possible 
of  haphazard  vaccination,  done  with  a  view  that  if  the 
operation  takes  effect  badly  it  can  be  done  again.  By 
such  a  proceeding  persons  often  take  vaccination  badly, 
and  cannot  be  made  to  take  it  properly  afterward ;  the 
imperfect  success  prevents  its  taking  fully  again,  and 
yet  some  day  they  may  take  small-pox  severely,  and 


246  HANDBOOK  OF   VACCINATION. 

perhaps  die  of  it.  Every  effort  should,  therefore,  be 
made  that  there  may  be  as  few  imperfect  vaccinations 
as  possible."* 

The  necessity  of  thoroughly  infecting  the  system  in 
vaccinating  had  been  inculcated  by  many  before  Marsort. 
But  it  is  to  him  that  we  owe  the  complete  demonstra- 
tion of  this  necessity ;  and  the  importance  of  his  labors 
it  is  impossible  to  exaggerate.  It  is  a  thing  to  be 
thankful  for,  that  the  resources  of  the  Small-pox 
Hospital — the  only  field  of  observation,  I  think,  in 
which  any  inquiry  of  this  kind  could  ever  have  been 
carried  to  such  a  complete  demonstration — should  have 
fallen  to  hands  so  competent  to  turn  them  to  account. 
And,  now  that  the  fact  is  established,  it  is  not  too  much 
to  affirm,  that  no  practitioner  will  have  done  his  duty 
in  any  case  in  which  he  is  called  upon  to  vaccinate, 
unless,  besides  taking  all  requisite  precautions  with  re- 
gard to  the  genuineness  of  the  lymph  he  employs,  and 
the  means  of  insuring  success,  he  has  also  taken  care 
to  vaccinate  sufficiently,  i.e.  to  produce,  so  far  as  in 
him  lies,  four  or  five  genuine  good-sized  vesicles,  such 
as  result  from  separate  punctures ;  or  if  vaccinating 
otherwise  than  by  separate  puncture,  to  produce  equiva- 
lent local  results. 

Whether  the  amount  of  local  effect  produced  in  vac- 
cinating has  the  same  relative  influence  in  altogether 
preventing  the  occurrence  of  small-pox  afterward,  that 
it  has  been  proved  to  have  in  modifying  the  character 
of  the  small-pox  if  it  should  be  contracted — whether 
persons  with  four  good  cicatrices  are  more  able  to  re- 
sist any  action  of  the  variolous  infection,  than  persons 

*  Art.  "Small-pox"  (op.  cit.),  p.  472. 


PROTECTION  AGAINST  SMALL-POX.         247 

with  only  one  good  cicatrix — there  are  not  facts  suffi- 
ciently numerous  and  precise  to  determine.  Analogy 
would  lead  us  to  believe  that  it  must  be  so:  and  facts, 
so  far  as  they  go,  tend  to  confirm  the  belief.  An 
attempt  was  made  in  1851-2,  by  the  Epidemiological 
Society,  to  throw  some  light  on  this  question  by  in- 
quiring of  medical  practitioners  as  to  the  marks  they 
personally  had  of  vaccination,  and  as  to  their  having 
suffered  or  not  from  any  form  of  variola  subsequently. 
But  the  replies  given  were  too  few  in  number,  and,  in 
some  instances,  too  vague  in  their  information,  to  justify 
any  positive  conclusion  being  drawn.  Out  of  347 
practitioners  who  stated  that  they  had  been  vaccinated 
in  childhood,  44,  or  126  per  cent.,  said  that  they  had 
subsequently  contracted  some,  generally  the  most- 
modilied  form  of  variola ;  but  these  included  some  cases 
in  which  the  variola,  as  it  was  called,  had  been  a  mere 
local  affection  taken  by  inoculation  from  small-pox 
corpses  in  the  dissecting-room.  Some  of  the  347  prac- 
titioners had  no  cicatrix  of  their  vaccination  ;  in  others 
the  cicatrices  were  imperfect,  or  were  only  one  or  two 
in  number  :  but  57  of  them  had  three  or  more  good 
vaccine  marks ;  and  of  these  57,  only  two,  or  35  per 
cent.,  had  had  subsequently  any  form  of  variola.*  In 
1863,  during  the  epidemic  of  small-pox  then  raging  in 
London,  Dr.  Buchanan  and  I,  in  the  course  of  an  ex- 
amination of  upwards  of  50,000  children  in  national 
and  infant  schools,  workhouses,  etc.,  with  the  view  of 
ascertaining  what  proportion  were  unvaccinated,  what 

*  Seaton  on  the  Protective  Powers  ofVaccination  (op.  cit.), 
p.  351.  It  deserves  note  that  this  proportion  very  closely  cor- 
responds with  the  proportion  in  which  those  who  were  pro- 
tected by  variolous  inoculation  had  small-pox  afterward. 


248 


HANDBOOK  OF   VACCINATION. 


proportion  had  been  vaccinated,  and  how,  among  these 
latter,  the  vaccination  had  been  done,  took  occasion 
also  to  note  how  far  the  children,  in  each  of  these  classes 
respectively,  had  marks  of  small-pox.  Forms  of  variola 
which  any  of  the  children  might  have  had,  which  left 
no  traces  whatever  behind,  we  were  obliged  to  leave 
out  of  account,  because,  unless  we  had  carried  our  in- 
quiries to  the  homes  of  the  children,  it  would  have 
been  impossible  to  ascertain  precisely  the  number  of 
such  cases.  They  had  been  comparatively  very  few : 
but  among  the  vaccinated  children  there  had  been 
some.  Hence  the  investigation  did  not  give  us  exactly 
the  information  we  had  been  desirous  to  obtain  as  to 
the  relative  effect  of  different  kinds  of  vaccination  in 
absolutely  preventing  any  manifestation  of  the  action 
of  the  variolous  poison — the  totally  preventive,  as  dis- 
tinguished from  the  modifying  power.  But  it  brought 
out  very  strongly  the  different  degrees  in  which  differ- 
ent kinds  of  vaccination  control  small-pox.  The 
following:  were  the  results  of  our  observations  : 


Classification  of  Children. 

Number 
examined  of 
each  class. 

Number  in 
each  class 
that  had 
traces  of 
Small-pox. 

Proportion 
having  traces 
of  Small-pox, 

per  1000 

children,  in 

each  class 

respectively. 

1.  Without  any  mark  of 
vaccination 

2,837 

508 

49,570 

1,010 
30 

88 

360 
59 

1-78 

2.  With  doubtful  mark 

of  vaccination. 
%3.  With  mark  or  marks 

And,  on  further  classification  of  the  vaccinated  chil- 


PROTECTION  AGAINST  SMALL-POX.         249 

dren  with  reference  to  the  kind  of  vaccination,  the  re- 
sults were  these: 

Proportion  having 
Marks  of  Smnll- 
Classification  of  Vaccinated  Children.  pox.  p  r  KKH) 

children,  in  each 
class  respectively. 

a.  Having  one  vaccine  cicatrix 680 

b.  Having  two  vaccine  cicatrices 2-49 

c.  Having  three  vaccine  cicatrices 1-42 

d.  Having  four  or  more  vaccine  cicatrices 0-67 

a.  Having  cicatrix  or  cicatrices  of  bad  quality... 7 -60 
/3.  Having    cicatrix    or    cicatrices    of    tolerable 

quality 235 

y.  Having    cicatrix    or    cicatrices   of    excellent 

quality 122 

The  extremes  were  represented  by  children  having 
four  or  more  vaccine  marks  of  perfect  character,  of 
whom  only  062  per  1000  had  a  trace  of  small-pox, 
and  children  having  a  single  vaccine  mark  of  bad 
quality,  of  whom  we  found  19  per  1000  with  marks  of 
small-pox.  But  these  numerical  statements  by  no 
means  bring  out  the  whole  difference  that  existed  be- 
tween the  vaccinated  and  the  unvaccinated,  or  between 
the  well  vaccinated  and  the  ill  vaccinated.  For  the 
marks  which  small-pox  had  left  on  most  of  the  vaccin- 
ated children,  and  particularly  on  the  well  vaccinated, 
were  very  slight — such  as  without  some  care  might 
have  passed  undetected — and  in  only  exceptional  cases 
were  in  the  least  disfiguring :  while  of  the  unvaccinated, 
a  very  large  proportion  were  seriously  marked  and 
disfigured,  some  being  really  hideous  to  look  at,  and 
several  suffering  from  permanent  blindness  and  deaf- 
ness, the  consequences  of  the  small-pox. 

It  has  often  occurred  to  me  that  probably  the  re- 
turns of  the  army,  in  which  service,  no  doubt,  both 
22 


250  HANDBOOK  OF   VACCINATION. 

the  character  and  number  of  the  vaccine  marks  pre- 
sented by  each  recruit  on  entering  are  exactly  re- 
corded, may  eventually  give  us  data  for  determining 
precisely  to  what  extent  the  amount  of  vaccination 
imparted  to  individuals  determines  their  relative  sub- 
sequent immunity  from  any  degree  of  action  of  the 
variolous  poison. 

(b)  Age. — It  is  a  mistake  to  suppose  that  post- vac- 
cinal small-pox  may  not  take  place  in  early  childhood, 
or  within  a  comparatively  short  period  from  vaccina- 
tion. In  those  in  whom  that  process  has  not  com- 
pletely exhausted  the  susceptibility  to  variola,  the 
modified  effects  of  the  variolous  infection  may  manifest 
themselves  at  any  period — even,  as  Willan  showed, 
within  a  few  weeks  or  months  of  the  vaccination.*  In 
the  returns  made  to  the  Epidemiological  Society,  in 
1852,  many  cases  of  post- vaccinal  small-pox  in  chil- 
dren under  ten  years  of  age,  were  included — occurring 
at  various  intervals  after  the  vaccination.  But  the 
modified  small-pox  of  young  children  is  generally  a 
very  trivial  affection, . and  of  the  light  varicelloid  form. 
In  some  cases  it  is  not  indeed  the  disease,  small-pox, 
at  all,  but  a  mere  local  affection,  without  the  usual  pre- 
monitory symptoms  of  small-pox,  resulting  from  inocu- 
lation by  sleeping  with,  or  playing  with  children  infected 
with  the  disease.  In  others,  when  it  arises  from  infec- 
tion, there  may,  probably,  with  severe  premonitory 
symptoms,  be  half  a  dozen,  or  a  dozen,  or  two  or  three 
dozen  pustules  only,  running  a  modified  course :  or  the 
eruption  may,  in  some  cases,  be  more  copious  but  still 
modified.     And  severe  cases  at  this  early  period  of  life 

*  Willan  on  Vaccine  Inoculation. 


PROTECTION  AGAINST  SMALL-POX.         251 

are  very  rare.  "  We  have  satisfactory  evidence,"  says 
Dr.  Gregory,  "that  under  fifteen  years  of  age,  the 
deaths  by  small-pox,  after  vaccination,  are  scarcely  no- 
ticeable;"* and  Marson,  also,  speaking  from  his  une- 
qualed  experience,  tells  us  that  among  children  under 
14  years  of  age,  who  have  been  vaccinated,  small-pox 
hardly  ever  proves  fatal. f  After  the  change  of  sys- 
tem which  takes  place  at  puberty,  not  only  is  post-vac- 
cinal  small-pox  of  more  frequent  occurrence,  but  the 
disease,  though  still  in  the  immense  majority  of  cases 

*  As  quoted  by  Simon,  op.  cit.,  p.  lxix. 

f  Petition  to  the  House  of  Commons  in  Papers  relating  to 
the  History,  etc.  (op.  cit.),  p.  25.  Exceptions  to  this  rule  are 
often  more  apparent  than  real — death,  when  it  does  occur, 
being  due,  not  to  small-pox,  but  to  some  concurrent  or  super- 
added disease.  I  may  notice  that  the  not  infrequent  entries  in 
our  death-registers  of  death  from  "  small-pox  after  vaccina- 
tion," in  young  children  of  all  ages,  often  when  only  one,  two, 
three,  four  years  old,  are  almost  invariably  incorrect  and  mis- 
leading. Some  years  ago,  on  personal  investigation  of  a  num- 
ber of  these  entries,  with  a  view  to  ascertain  their  real  value, 
I  found  that  in  every  case  included  in  my  inquiry,  except  one, 
either  (1)  there  had  been  no  attempt  at  vaccination,  the  parent 
having  given  a  false  answer  to  the  Registrar's  question,  under 
fear  that  he  should  be  subjected  to  penalty  if  he  gave  the  true 
one;  or  (2)  that  vaccination  had  been  indeed  attempted,  but 
had  never  taken  effect ;  or  (3)  that  the  vaccination  had  been 
performed  while  the  patient  was  incubating  small-pox.  One 
child  only,  between  11  and  12  years  of  age,  whom  the  mother 
stated  to  have  been  successfully  vaccinated  when  an  infant, 
and  to  have  retained  a  mark  on  the  arm,  appeared  to  have 
died  of  the  hemorrhagic  form  of  small-pox.  As  the  child 
was  buried  I  had  no  opportunity  of  seeing  the  mark,  and  the 
doctor  who  attended  the  case  had  never  thought  of  looking 
at  it. 


252  HANDBOOK   OF    VACCINATION. 

light  and  modified,  runs  in  some  cases  a  severer 
modified,  and  in  some  an  unmodified,  course  —  de- 
pending chiefly,  as  has  been  seen  in  the  preceding 
subsection,  on  the  quality  of  the  vaccination.  The 
table  given  at  page  237,  showing  the  different  forms  in 
which  post-vaccinal  small-pox  manifested  itself  at  the 
Small-pox  Hospital,  may  bo  taken  as  referring  substan- 
tially to  cases  after  puberty,  the  post-vaccinal  cases 
received  for  treatment  in  the  hospital  before  that 
period  of  life  being  comparatively  very  few.*  This 
much  more  frequent  occurrence  of  severe  post-vaccinal 
small-pox  in  persons  who  are  grown  up  than  in  chil- 
dren, has  been  held  by  some  to  give  countenance  to  the 
hypothesis  that  the  influence  of  vaccination  in  the  in- 
dividual is  but  temporary,  that  it  diminishes  by  lapse 
of  time,  and  tends  gradually  to  wear  out:f  and  there 
have  been  all  sorts  of  arbitrary  assumptions  that  vac- 
cination holds  good  for  seven  years,  or  for  ten  years, 
or  for  fourteen  years,  etc.  Dr.  Gregory  pointed  out, 
upwards  of  thirty  years  ago,  that  no  real  grounds  had 
ever  been  shown  for  the  doctrine  thus  propounded,  and 

*  There  are  obvious  reasons  why  young  children  affected 
with  small-pox,  especially  if  the  disease  be  not  severe,  would 
be  treated  at  home  rather  than  sent  to  a  hospital ;  still,  in  the 
years  which  the  return  includes  (1836-51),  a  great  number  of 
unprotected  young  children  were  admitted. 

f  The  hypothesis  itself  dates  from  the  earliest  days  of  vac- 
cination, before  there  could  be  facts  to  establish  it.  The  same 
hypothesis  had  been  advanced  with  regard  to  variolous  inocu- 
lation, by  the  opponents  of  that  practice.  Jenner  had  an- 
swered it,  as  regards  cow-pox,  by  anticipation  in  his  "In- 
quiry," showing  that  milkers  who  had  contracted  the  cow-»pox 
thirty  or  forty  years  before  were  as  safe  as  those  recently 
infected. 


PROTECTION  AGAINST  SMALL-POX.         253 

the  facts  that  have  since  accumulated  satisfactorily 
prove  that  it  is  not  in  this  way  that  the  greater  fre- 
quency and  severity  of  small-pox  in  vaccinated  per- 
sons after  puberty  than  in  childhood  is  to  be  explained. 
For,  if  the  influence  leading  to  this  result  consisted  in 
a  mere  wearing  out  of  the  protection  by  lapse  of  time, 
it  would  be  steadily  progressive,  and  in  observations 
on  large  masses  of  vaccinated  populations  at  different 
ages,  we  should  find  the  liability  to  small-pox  becoming 
greater,  the  greater  the  age,  or  the  longer  the  time  that 
had  elapsed  since  the  performance  of  the  vaccination. 
But  that  this  is  not  the  case  is  shown  by  observations 
made  for  a  long  series  of  years  on  the  troops  of  the 
British  army  serving  in  the  United  Kingdom ;  for 
while  the  deaths  from  small-pox  among  every  10,000 
soldiers  serving  under  twenty  years  of  age,  were  3  4, 
and  among  every  10,000  soldiers,  from  twenty  to 
twenty-five  years  old,  were  31,  the  deaths  from  this 
cause  among  soldiers  above  twenty-five  years  of  age 
were  but  1  per  10,000.*  In  like  manner,  the  great 
bulk  of  admissions  of  cases  of  post-vaccinal  small-pox 
into  the  London  Small-pox  Hospital  is  found  to  take 
place  between  the  ages  of  fifteen  and  twenty-five :  after 
the  age  of  twenty-five  there  is  a  remarkable  diminu- 
tion, j-  And,  correspondingly,  observations  which  were 
collected  by  Heim  of  1055  cases  of  small-pox  in  vac- 
cinated persons,  with  special  reference,  not  so  much  to 
the  age  of  the  individuals,  as  to  the  number  of  years 
that  had  elapsed  since  the  vaccination,  showed  that 

*  T.  G.  Balfour,  on  the  Protection  against  Small-pox  afforded 
by  Vaccination,  in  Medico-Chir.  Trans.,  vol.  xxxv. 
f  Marson  in  Medico-Chir.  Trans.,  vol.  xxxvi.  table  v. 
22* 


254  HANDBOOK  OF   VACCINATION. 

while  the  average  annual  number  of  cases  in  the  first 
twelve  years  after  vaccination  was  twelve,  and  in  the 
next  thirteen  years  was  over  fifty-one,  the  average  for 
the  following  ten  years  was  under  twenty-five.  The 
facts  find  their  best  explanation,  as  Dr.  Gregory  sug- 
gested, in  the  disturbing  influence  of  puberty,  and  they 
point  to  the  importance  of  renewing  the  vaccine  pro- 
cess after  that  change  has  taken  place. 

(c)  Personal,  Hereditary,  or  Family  tendency. — 
Some  persons  appear  to  be  peculiarly  susceptible  of  the 
action  of  the  variolous  poison.  I  have  alluded  before 
to  recorded  cases  of  persons  having  small-pox  three 
times  and  oftener.  A  friend  of  my  own,  one  of  the 
most  careful  and  observant  of  practitioners,  saw  a  case 
of  small-pox  in  a  vaccinated  person,  and  saw  this 
attack  succeeded  after  an  interval  of  years  by  another 
attack :  and  I  have  been  furnished  with  notes  of  a  case 
of  a  naval  officer  who  was  vaccinated  in  infancy,  got 
confluent  small-pox  in  South  America,  and  had  another 
confluent  attack  afterward  at  Bath.  One  vaccinated 
medical  practitioner  of  my  acquaintance  gave,  on  each 
epidemic  of  variola  to  which  he  had  been  exposed,  some 
manifestation  of  the  action  on  his  system  of  the  vario- 
lous poison,  though  once  it  amounted  only  to  an  efflo- 
rescence following  on  the  premonitory  symptoms,  and 
once  was  altogether  limited  to  the  premonitory  symp- 
toms. But  the  misfortune  is,  that  we  have  no  outward 
signs  whereby  to  recognize  beforehand  these  particu- 
larly disposed  individuals.  If  a  dozen  children  be 
vaccinated,  and  the  vaccination  go  through  its  course 
regularly  in  all,  we  know  for  certain  that  nine,  ten,  or 
eleven  of  them  will  be  safe  for  life  against  any  assault 
of  small-pox,  while  possibly  in  one,  two,  or  three  the 


PROTECTION  AGAINST  SMALL-POX.         255 

susceptibility  to  some  degree  of  future  action  of  the 
variolous  infection  may  remain :  but  there  is  nothing  to 
tell  us  beforehand  which  are  the  permanently  and  com- 
pletely, and  which  the  less  completely,  protected.  One 
thing,  however,  which  would  lead  us  to  anticipate  a 
special  liability  to  post-vaccinal  small-pox,  would  be 
the  previous  occurrence  of  such  an  event  in  more  than 
one  member  of  the  family.  There  can  be  no  doubt 
that  the  variolous  diathesis  exists  more  in  some  fami- 
lies than  in  others.  Dr.  Kendrick  of  Warrington,  in  an 
account  of  434  cases  of  post-vaccinal  small-pox  with 
which  he  favored  the  Epidemiological  Society,  noted 
that  276  of  these  were  single  cases,  no  other  members 
of  the  family  being  attacked,  but  that  there  were  37 
families  which  had  2  cases,  13  which  had  3,  7  which 
had  4,  2  which  had  5,  and  1  which  had  7  cases ;  and  in 
a  similar  communication  of  125  cases  of  post-vaccinal 
small-pox,  Mr.  Grove,  of  Wandsworth,  related  that  28 
only  were  single  cases,  there  being  14  families  which 
had  2,  10  which  had  3,  7  which  had  4,  1  which  had  5, 
and  1  which  had  6  cases.*  Mr.  Marshall  has  recorded 
the  circumstance  of  twelve  brothers  and  sisters,  of  ages 
varying  from  five  to  twenty-four  years,  all  of  whom  had 
been  vaccinated  when  infants,  being  all  attacked  to- 
gether, during  an  epidemic  of  small  pox,  with  the 
mildest  and  most  modified  form  of  that  disease ;  the 
father  and  mother  also  sustaining  a  mild  attack,  though 
the  former  had  been  twice  vaccinated  with  effect,  and 

*  Of  course,  in  the  different  families  inquired  into,  whether 
by  Dr.  Kendrick  or  Mr.  Grove,  there  were  differences  in  the 
degrees  of  exposure  to  infection,  some  persons  being  much 
more  careful  as  to  isolation,  etc.  than  others,  but  this  did  not 
explain  the  whole  difference. 


256  HANDBOOK  OF   VACCINATION. 

the  latter  had  had  small-pox  when  she  was  five  years 
old ;  the  only  person  in  the  family  who  escaped  was 
the  grandfather,  who  was  seventy-eight  years  old,  and 
who  had  been  vaccinated  at  the  age  of  forty-eight.  He 
also  states  that  during  the  same  epidemic  in  which  he 
witnessed  this  occurrence,  he  attended  no  fewer  than 
five  cases  of  second  small-pox,  four  of  which  were  in 
two  branches  of  the  same  family.*  Simon  relates  a 
case,  communicated  to  him,  of  three  brothers,  vaccin- 
ated in  infancy,  who  all  contracted  small-pox  subse- 
quently, one  by  infection  from  without  and  the  other 
two  by  infection  from  him,  when  their  ages  were  re- 
spectively thirteen,  eleven,  and  seven  years,  and  who 
all  had  a  further  attack  some  years  afterward.  He 
gives,  on  the  authority  of  Dr.  Arnott,  a  case  of  post- 
vaccinal confluent  small-pox,  in  a  patient  whose  father 
had  had  small-pox  twice,  and  an  uncle  three  times, 
another  uncle  having  died  from  a  first  attack  of  the 
disease ;  and  he  refers  to  an  instance  of  three  brothers 
and  sisters  having  post-vaccinal  small  pox,  one  of 
them  once,  another  twice,  and  the  other  three  times, 
the  third  attack  in  the  last  proving  fatal. f 

Medical  friends  have,  on  various  occasions,  informed 
me  of  cases — especially  during  the  severe  epidemic  of 
small-pox  which  has  prevailed  since  1863 — in  which, 
while  some  members  of  families  were  suffering  from 
post-vaccinal  small-pox,  some  other  member  of  the 
family,  who  had  had  small-pox  before,  by  inoculation 

*  Mr.  Marshall  in  Lancet,  vol.  xxxvi. 

f  Simon,  Preface  to  Papers  relating,  etc.  (op.  cit.),  p.  xxx. 
The  last  case  is  reported  by  Dr.  Webster  in  the  Lancet,  vol.  i. 
for  1861,  p.  271. 


PROTECTION  AGAINST  SMALL-POX.         257 

or  otherwise,  had  been  again  affected  with  that  disease. 
And  several  instances  have  come  to  my  knowledge  in 
which  brothers  vaccinated  in  infancy  have  each  soon 
after  puberty  had  post-vaccinal  small-pox. 

(d)  Change  of  Climate. — The  protection  which  vac- 
cination gives  against  small-pox  is  seen  in  all  races  of 
mankind,  and  in  all  climates  (§  94)  ;  but  change  from 
one  climate  to  another,  when  that  change  involves 
considerable  variation  of  temperature,  would  seem  to 
render  vaccinated  persons  in  many  instances  more 
susceptible  of  small-pox.  It  is  certainly  often  noted 
that  persons  get  that  disease  soon  after  passing  from 
a  temperate  to  a  tropical  or  a  very  hot  region — as  from 
England  to  India — or  vice  versa,  especially  when  the 
cicatrices  are  not  very  well  marked.  The  influence  of 
climatic  change  is  evident,  I  think — though  it  is  impos- 
sible to  separate  it  from  the  influence  of  other,  and  no 
doubt  more  powerful,  causes  (especially  those  to  be 
noticed  in  the  next  subsection) — in  the  much  more 
frequent  occurrence  of  small-pox  among  our  soldiers 
employed  in  China,  and  among  our  sailors  serving  in 
China  and  Japan,  than  in  any  other  section  of  the 
British  army  and  navy.  While  the  small-pox  cases  in 
the  entire  British  navy,  during  the  six  years  1859-64, 
were  but  4  2  per  1000  of  the  mean  force ;  and  on  the 
whole  force,  if  we  except  the  East  India  and  China 
squadron*  were  but  31  per  1000,  the  cases  in  that 


*  By  an  alteration  which  took  place  early  in  1864,  the  East 
Indies  were  detached  from  the  China  station  and  added  to  the 
Cape  of  Good  Hope  command.  But  "  the  force  employed  in 
the  East  Indies  had  always  been  so  very  small  that,  practi- 
cally, its  withdrawal  from  one  station  and  its  addition  to  the 


258  HANDBOOK  OF   VACCINATION. 

squadron  exceeded  13  per  1000.*  And  during  the  same 
six  years,  while  the  cases  of  small-pox  among  the 
troops  serving  in  the  United  Kingdom  were  less  than 
one  and  a  half  per  1000,  they  amounted  among  the 
white  troops  in  China  to  nearly  6  per  1000.f  The 
black  troops  in  China  suffered  very  little  from  small- 
pox, the  ratio  of  small-pox  cases  among  them  having 
during  the  six  years  been  considerably  less  than  one 
per  1000  of  the  force.  This  arose  mainly  from  differ- 
ence of  stationing,  exposing  them  much  less  than  the 
whites  to  the  infection  of  that  disease,  especially  dur- 
ing the  epidemic  year  of  1862,  which  year  alone  sup- 
plied about  half  the  total  number  of  the  cases  that 


other  has  had  little  or  no  effect,  in  a  statistical  point  of  view, 
on  the  returns  of  either."  (Statistical  Report  of  Health  of 
Navy  for  1864.) 

*  The  difference  is  probahly  not  so  great  as  these  numbers 
would  show,  because  some  of  the  cases  of  small-pox,  both  at 
home  and  abroad,  occurred  in  individuals  not  vaccinated,  and 
it  is  fairly  presumable  that,  in  the  event  of  men  joining  who 
were  unprotected,  there  would  be  more  difficulty  in  getting 
vaccination  done  on  the  China  station  than  on  the  Home  or 
many  other  stations.  The  navy  is  not,  as  regards  small-pox, 
an  entirely  protected  force.  The  admirable  statistical  returns, 
yearly  published,  frequently  mention,  in  cases  of  small-pox, 
that  the  persons  had  not  been  vaccinated.  But  unfortunately 
the  surgeons  of  a  very  large  number  of  ships,  in  their  returns 
of  small-pox  cases,  omit  to  give  any  definite  and  reliable  in- 
formation with  regard  to  vaccination. 

f  The  soldiers  both  in  the  United  Kingdom  and  in  China 
were  an  entirely  protected  force.  The  cases  of  small-pox  in 
China  in  the  six  years  were  135 ;  all  the.  individuals  attacked 
had  marks  of  vaccination  except  two,  and  these  had  marks  of 
former  small-pox.     One  of  these  two  died. 


PROTECTION  AGAINST  SMALL-POX.         259 

occurred  in  the  entire  force  during  the  whole  period. 
But  climatic  change  had  probably,  too,  its  influence : 
for  the  general  health  of  the  black  troops  was  much 
less  affected  by  the  change  of  climate  than  that  of  the 
whites. 

But  change  of  climate  has  probably  a  much  greater 
and  more  decided  effect  in  influencing  the  course 
and  character  of  post-vaccinal  small-pox,  if  con- 
tracted, than  in  disposing  the  system  to  contract  it. 
Of  658  cases  of  post-vaccinal  small-pox  among  the 
troops  in  the  United  Kingdom,  from  1859  to  1864,  38 
were  fatal,  of  5  8  per  cent  ;  but  of  614  cases  of  small- 
pox among  the  troops  in  India,  from  1860  to  1864,  90 
were  fatal,  or  14*6  per  cent.;  and  of  the  133  post-vac- 
cinal cases  in  the  China  force,  from  1859  to  1864,  20 
were  fatal,  or  15  per  cent.* 

The  influence  of  change  of  climate  in  disposing  to 
small-pox  is  noticeable  in  persons  protected  by  variolous 
inoculation,  or  by  previous  natural  small-pox,  as  well 
as  in  the  vaccinated.  In  them,  also,  Marson  tells  us, 
the  disposition  to  contract  the  disease  a  second  time  is 
promoted  by  any  great  climatic  change,  whether  from 
a  hotter  to  a  colder,  or  from  a  colder  to  a  hotter 
region,  f 

(e)  Frequency  and  Extent  of  Exposure  to  the  Vari- 
olous Infection. — The  influence  which  these  must  ex- 
ercise is  obvious.  Whatever  the  protection  or  non- 
protection  of  individuals,  they  cannot  contract  variola, 

*  Specific  information  on  the  quality  and  amount  of  the  vac- 
cination in  these  cases  would  have  been  most  important :  but 
the  facts  in  the  text  point  to  the  extreme  necessity  of  renew- 
ing the  vaccine  protection  after  great  climatic  change. 

f  Art  "Small-pox"  (op.  cit.),  p.  452. 


200  HANDBOOK  OF   VACCINATION. 

unless  they  come  in  contact  with  its  specific  cause. 
Hence,  our  soldiers  and  sailors  employed  on  various 
foreign  stations,  from  which  small-pox  is  sometimes 
absent  for  long  periods  together,  suffer  much  less 
from  that  disease  than  those  who  are  employed  at 
home,  who  are  mostly  quartered  in,  or  stationed  near, 
large  towns,  where  the  infection  of  small-pox  is  often 
prevailing.  In  Australia  and  New  Zealand,  no  case 
of  small-pox  has  occurred,  either  in  the  army  or  navy, 
for  a  long  series  of  years.  Again,  also,  where  small- 
pox is  present,  the  degrees  of  exposure  may  vary  infi- 
nitely. , 

The  Registrar-General  for  Scotland,  in  his  annual 
reports,  classifies  the  small-pox  mortality  of  that  king- 
dom in  a  way  which  gives  a  good  general  illustration 
of  the  effect  of  frequency  of  exposure  to  the  variolous 
contagion.  He  compares  each  year  the  small-pox 
deaths  occurring  among  the  population  dwelling  in 
the  islands  of  Scotland,  in  the  rural  districts  of  the 
mainland  of  Scotland,  including  small  towns  and  vil- 
lages, and  in  the  towns  of  10,000  inhabitants  or  more. 
The  following  table,  which  I  have  compiled  from  these 
reports,  shows  the  results  for  ten  years,  per  100,000 
of  the  population,  in  each  class  of  the  district: 


PROTECTION  AGAINST  SMALL-POX. 


261 


Year. 


1855... 
1856... 
1857... 
1858... 
1859... 
1860... 
1861... 
1862... 
1863... 
1864... 

Totals 


Small-pox  Deaths  per  100,000,  living 


In  Insular 
Districts. 

In  Rnral 
Districts  and 
Small  Towns. 

In  Towns  of 
10,000  In- 
habitants 
or  more. 

17 

34 

75 

11 

26 

84 

16 

11 

61 

6 

8 

17 

5 

10 

46 

21 

33 

83 

4 

16 

44 

1 

6 

27 

10 

37 

87 

19 

48 

78 

110 


229 


602 


There  is  no  reason  whatever  for  supposing  that  the 
insular  and  rural  districts  are  better  vaccinated  than 
the  large  towns :  the  probability  is  that  it  is  just  the 
reverse.  Their  small  relative  mortality  from  small-pox 
is  due  to  their  being  much  less  exposed  to  the  infection. 
In  the  large  towns  of  England,  it  is  a  matter  of  daily 
observation  that  much  of  the  small-pox  met  with  occurs 
in  unvaccinated  persons  who  have  immigrated  from 
rural  districts. 

Extent  of  exposure  to  the  small-pox  infection  is  of 
no  less  consequence  than  frequency  of  exposure.  The 
degree  may  vary  from  the  merest  chance  contact  with 
an  infected  person  or  thing,  to  the  occupying  the  same 
house,  room,  or  bed,  with  a  variolous  patient.  Inter- 
esting inquiries  have  at  times  been  made,  as  to  the 
23 


262 


HANDBOOK  OF   VACCINATION. 


protection  which  vaccination  afforded  to  persons  ex- 
posed to  the  small-pox  infection  in  the  utmost  degree. 
Mr.  Cross,  of  Norwich,  during  a  severe  epidemic  of 
small-pox  which  prevailed  in  that  city  in  1819,  noted 
what  took  place  in  112  families,  in  which  he  had,  be- 
tween the  months  of  March  and  August,  attended 
above  200  cases  of  small-pox,  there  being  at  least  one 
case  in  each  family.  The  following  are  the  results  of 
his  observations,  reduced  to  a  tabular  form : 


Protection  or  non-protection  of 
Individuals. 

Number  of 
Persons. 

Cases  of 
Small-pox. 

Death  s  from 
Small-pox. 

1.  Protected  by  former 

297 

91 
215 

2.  Protected    by   Vac- 

2 
200 

3.  Unprotected 

46 

Totals   in  the  112  in- 
fected households 

603 

202 

46 

The  91  vaccinated  persons  were  continually  in  the 
same  rooms,  and  many  of  them  occupied  the  same  beds, 
with  variolous  patients,  and  the  only  two  individuals 
among  them  who  took  the  small-pox  had  it  in  its 
most  modified  form.  At  the  time  the  epidemic  was  at 
its  height,  Mr.  Cross  extended  his  inquiries  to  families 
in  parts  of  the  town  with  which  he  was  little  ac- 
quainted, and  found  that,  "in  31  families,  those  who 
had  had  cow-pox  were  living  in  the  same  room,  or  lying 
in  the  same  bed,  with  others  suffering  or  dying  from 
natural  small-pox,  yet  remained  perfectly  safe,  with 
the  exception  "only  of  one  child,  whose  mother  reported 
that  it  had  ten  pustules."     In  the  whole  inquiry  It 


PR 0 TECTION  A  GAINST  SMA  LIs-POX.         263 

families  were  met  with  in  which  the  vaccinated  lived 
in  the  same  room  with  small-pox :  and  not  one  indi- 
vidual among  them  had  any  serious  disease,  and  not 
above  one  in  thirty  had  any  eruptive  disease  at  all.* 
In  1838-9,  Mr.  Marshall,  of  Chelsea,  made  inquiries 
respecting  757  persons,  who  during  an  epidemic  of 
small-pox  which  then  prevailed  in  that  parish  had  been 
exposed  in  an  excessive  degree  to  the  contagion,  inas- 
much as  they  were  all  members  of  infected  families, 
and  a  large  proportion  of  them  had  occupied  the  same 
rooms  with  the  small-pox  cases.  Of  the  757  persons, 
231  were  stated  to  have  been  vaccinated,  and,  of  these, 
27  had  suffered  from  small-pox  in  some  form  during 
the  epidemic.  Of  the  remaining  526,  Mr.  Marshall 
does  not  state  how  many  were  protected  by  previous 
small-pox,  or  were  without  protection  :  but  he  tells  us 
that  of  those  who  were  unprotected  only  7  escaped 
attack  during  this  outbreak.  There  were  among  the 
526  individuals  fourteen  alleged  cases  of  second  small- 
pox, the  character  of  the  attack  in  these,  as  compared 
with  the  post-vaccinal  cases,  being  as  follows : 

*  Cross,  A  History  of  the  Variolous  Epidemic  which  pre- 
vailed in  Norwich,  etc.  8vo.  Lond.  1820.  A  very  interesting 
and  valuable  work.  In  all  the  cases  in  which  vaccination  had 
been  performed,  Mr.  Cross  examined  the  cicatrices.  During 
the  epidemic,  several  hundreds  of  persons  vaccinated,  at  times 
varying  from  the  earliest  period  of  the  practice  to  within  a 
few  weeks,  were  tested  by  variolous  inoculation,  without  the 
production  in  any  instance  of  the  regular  small-pox. 


264  HANDBOOK  OF  VACCINATION. 

Second  Small-pox.  Post-vaccinal  Small-pox. 

Mild  cases 7     Mild   cases,  unattended 

Severe   cases,  but  recov-  with  fever,  with  a  few 

erod 4        isolated  pustules, vary- 

Severe  cases,  fatal 3         ing  in  number  from  2 

—        to  70 22 

14     Modified,  attended  with 
constitutional  disturb- 
ance, but  recovered...     4 
Fatal 1 

27 

The  number  of  alleged  cases  of  second  small-pox  is 
so  extraordinary,  that  we  can  hardly  suppose  but  that 
there  must  have  been  some  error  of  statement  to  Mr. 
Marshall  with  regard  to  some  of  them.  Five,  how- 
ever, passed  under  his  own  observation,  four  of  these 
being,  as  already  stated  (p.  255),  in  two  branches  of 
the  same  family.*  Dr.  Paine,  of  Cardiff,  during  a 
most  severe  epidemic  of  small-pox  which  prevailed  in 
that  town  in  1857,  made  inquiry  respecting  1722  per- 
sons living  in  four  streets  in  which  the  disease  partic- 
ularly prevailed.  Of  these  persons  1011  were  adults, 
of  whom  only  8  contracted  small-pox,  and  711  were 
children,  of  whom  88  contracted  small-pox.  And  re- 
specting the  children,  the  following  further  particulars 
were  made  out : 

*  Lancet,  vol.  xxxvi. 


PROTECTION  AGAINST  SMALL-POX. 


265 


Protection  or  non-protection 
of  Individuals. 

Nnmber  of 
Children. 

Case*  of 
Small-pox. 

Proportion 
per  cent, 
infected. 

1.  Protected  by  former 

small-pox 

2.  Protected  by  Vaccin- 

33 
608 

70 

18 
70 

2-96 
100 

The  vaccinated  children,  in  many  instances,  occupied 
the  same  rooms,  and  frequently  the  same  beds,  with 
small-pox  cases;  and  in  every  one  of  the  18  among 
them,  who  were  in  any  degree  infected,  the  disease 
was  exceedingly  modified.* 

Probably  the  extreme  of  closeness  and  constancy  of 
exposure  is  to  be  found  on  board  an  infected  ship  ;  for 
(1)  the  cubic  sleeping  space  that  can  be  allowed  to 
each  person  on  board  ship  is  necessarily  very  limited ; 
and  (2)  whatever  endeavors  may  be  made  to  isolate 
infected  individuals,  when  once  the  atmosphere  of  a 
ship  has  become  variolated,  there  is  no  escape  from  it, 
it  must  always  be  breathed.  Persons  on  shore,  living 
in  infected  houses  or  rooms,  can  generally,  at  all  events, 
for  some  hours  in  the  day,  get  away  from  the  specially 
infected  air  of  the  house  or  room ;  but  there  is  no  run- 
ning away  from  the  infected  air  of  aboard  ship.  Where 
such  an  atmosphere  has  to  be  constantly  breathed  by 
adults,  whose  systems  may  probably,  at  the  same  time, 
be  particularly  predisposed  to  infection  from  the  action 
of  climatic  change  and  of  epidemic  influence,  the  value 
of  a  single  vaccination  in  infancy  or  early  childhood  is 


*  Fifth  Annual  Report  on  Sanitary  Condition  of  Cardiff. 
8vo.    Cardiff,  1858. 

23* 


266  HANDBOOK  OF   VACCINATION. 

perhaps  put  to  the  severest  test  that  can  be  applied  to 
it.  On  Dec.  4,  1860,  small-pox  made  its  appearance 
on  board  H.M.S.  the  Imperieuse,  then  at  anchor  off 
the  Peiho,  but  which  sailed  that  very  day  for  Japan. 
A  fortnight  afterward  (Dec.  18),  when  the  ship  was 
at  anchor  off  Nagasaki,  two  other  cases  broke  out,  and 
these  were  followed  by  others  in  rapid  succession  till 
the  25th  of  January,  1861,  after  which  date  no  case 
occurred.  Of  the  505  men  and  officers  who  constituted 
the  force  of  the  vessel,  who  were  nearly  all,  but  not 
all,  vaccinated,  148  gave  some  evidence  or  other  of 
having  been  affected  by  the  variolous  poison.  In  15, 
all  of  them  vaccinated,  there  was  simply  the  variolous 
fever,  without  any  eruption.  The  remainder  exhibited 
every  form  of  the  variolous  eruption,  from  the  mildest 
modified  to  the  confluent  and  malignant  form.  A  hun- 
dred and  eleven  cases,  with  five  deaths,  occurred  in 
men  with  fair  vaccine  marks  (unfortunately  the  num- 
ber of  marks  in  the  respective  cases  is  not  stated),  13 
cases  with  three  deaths  in  men  with  imperfect  vaccine 
marks,  and  9  cases  with  two  deaths  in  men  who  had 
no  mark  of  vaccination  whatever.*  On  Feb.  3,  1864, 
small-pox  made  its  appearance  on  board  H.M.S.  Eury- 
alus,  then  stationed  off  the  coast  of  Japan,  and  it  con- 
tinued until  the  19th  of  April.  During  this  period 
there  occurred,  among  the  510  officers  and  men  who 
constituted  the  complement  of  the  vessel,  and  who 
were  with  few  exceptions  protected,  40  cases  of  a  sim- 
ple fever  (which  the  surgeon  considered  to  be,  and 
which  from  the  description  evidently  was,  variolous 

*  Statistical  Report  of  the  Health  of  the  Navy  for  the  Tear 
1860. 


PROTECTION  AGAINST  SMALL-POX.         267 

fever),  with  or  without  an  attendant  rash,  but  without 
any  development  of  vesicles;  and  72  cases  of  some 
kind  or  other  of  variolous  eruption.  In  20  cases,  this 
eruption  amounted  to  one  or  two,  or  a  few,  umbilicated 
vesicles  only;*  in  35  there  was  a  discrete  and  generally 
modified  eruption  of  variola;  and  in  17  a  confluent 
eruption.  The  different  forms  of  attack  among  the 
vaccinated  are  reported  to  have  been  chiefly  influenced 
by  the  kind  of  vaccine  cicatrices.  When  these  were 
well  marked  and  foveated,  the  susceptibility,  according 
to  the  report  of  Mr.  Morgan,  the  surgeon  of  the  vessel, 
was  comparatively  small:  the  greater  number  of  per- 
sons with  such  marks  having  the  variolous  fever  only, 
with  or  without  rash,  or  having  but  a  few  vesicles. 
Among  the  35  cases  of  discrete  eruption,  two  occurred 
in  persons  who  had  previously  had  small-pox,  one  of 
them  being  well  pitted  from  his  former  attack,  and  the 
rest  in  persons  with  vaccine  marks  which  were  good, 
but  not  so  good  or  so  numerous  as  in  the  class  of  pa- 
tients just  referred  to :  those,  says  Mr.  Morgan,  who 
had  the  variolous  fever,  or  very  slight  eruption  only, 
"were  all  of  them  well  marked  on  both  arms,  whereas, 
the  majority  of  these  were  marked  on  one  arm  only." 
In  all  the  confluent  cases,  vaccination  marks  could 
either  not  be  seen,  or  were  ill  defined  and  not  good. 
Six  of  the  confluent  cases  died,  and  one  was  invalided. 
Of  these  seven  cases,  one  was  ascertained  not  to  have 


*  "In  two  officers  who  were  covered  with  patches  of  the 
peculiar  scarlet  rash  on  the  trunk  and  the  upper  extremities, 
only  one  solitary  vesicle,  which  was  depressed  in  the  center 
and  surrounded  by  a  red  areola,  appeared,  in  one  case  on  the 
face  and  in  the  other  on  the  back."  (Stat.  Rep.  of  the  Health 
of  the  Navy  for  1864,  p.  245.) 


268  HANDBOOK  OF   VACCINATION. 

been  vaccinated ;  three  had  no  vaccination  marks  what- 
ever; in  two  the  vaccination  marks  were  indistinct, 
and  one  had  cicatrices  on  both  arms,  which  though 
distinct,  were  not  foveated.*  An  outbreak  of  small- 
pox occurred  on  board  H.M.S.  Octavia,  in  1866,  which 
was  very  remarkable  for  the  rapidity  with  which  the 
infection  spread.  The  disease  was  introduced  into  the 
ship  at  the  end  of  February;  it  began  to  spread  on  the 
17th  of  March,  and  between  that  date  and  the  27th 
of  March  inclusive — that  is  to  say,  in  the  space  of 
eleven  days — no  fewer  than  164  officers  and  men  mani- 
fested some  degree  of  affection  from  the  variolous  poison. 
No  case  occurred  after  the  27th  of  March.  The  follow- 
ing particulars,  with  regard  to  the  protection  of  the 
officers  and  crew,  are  given  in  the  journal  of  the  sur- 
geon of  the  ship:f  "On  the  1st  of  March,  when  the 
Octavia  left  Bombay  for  the  Persian  Gulf,  there  were 
on  board  610  officers  and  men;  of  these,  589  were 
'protected'  by  vaccination,  and  twenty-one  (fourteen 
of  whom  were  Kroomen,  shipped  at  Sierra  Leone  when 
the  Octavia  was  on  her  way  out  from  England  in 
October  of  last  year)  were  'unprotected.'  Of  those 
protected,  437  escaped  altogether,  while  147,  or  249 
per  cent.,  were  only  attacked  with  symptoms  of  pri- 
mary fever,  or  with  the  disease  in  a  distinct  and  com- 
paratively mild   form,|  all  of  whom  recovered;   and 

*  Statistical  Report  of  the  Health  of  the  Navy  for  the  Year 
1864. 

f  For  this  extract  I  have  to  express  my  best  thanks  to 
Deputy  Inspector-General  Mackay,  of  the  Admiralty. 

J  Of  these  persons  85,  or  14-4  per  cent.,  had  merely  the 
variolous  fever,  and  only  62,  or  10-5  per  cent.,  had  any  form, 
however  modified,  of  variolous  eruption.     See  return  relating 


PROTECTION  AGAINST  SMALL-POX.         269 

only  five,  or  08  per  cent.,  were  attacked  with  the  con- 
fluent form,  and  those  also  all  recovered.  While  of 
the  'unprotected'  all  were  attacked,  18  or  85-T  per 
cent,  with  the  disease  in  its  confluent  form,  of  whom 
six  died;  and  three;  or  142  per  cent.,  with  severe 
attacks  of  the  distinct  form,  all  of  whom,  however, 
recovered."* 

(f )  Intensity  of  Epidemic  Influence. — Like  scarlet 
fever,  measles,  etc.,  small-pox  not  only  has  its  periods 
of  peculiar  prevalence,  conveniently  called  epidemic 
periods,  but  at  some  of  these  it  manifests  a  much 
greater  activity  and  virulence,  and  is  attended  with 
greater  fatality  than  at  others.  This  occasional  differ- 
ence in  the  severity  of  different  small-pox  epidemics 
was  remarked  on  by  Jenner,  who  in  his  first  treatise 
refers  to  a  singularly  mild  epidemic  which  he  had  wit- 
nessed some  years  before  in  the  County  of  Gloucester. f 
The  epidemic  which  prevailed  in  the  greater  part  of 
England  in  1858,  and  which  invaded  London  in  1859- 
60,  was  a  severe  epidemic;  but  its  intensity  was  much 
less  than  that  of  the  epidemic  which,  beginning  toward 
the  end  of  1 862,  has  continued  more  or  less  to  the  pres- 
ent time.  The  mortality  in  London  from  small-pox  in 
1863  was  greater  than  had  been  known  for  upwards  of 
twenty  years.  It  occurred,  as  at  all  other  times,  chiefly 
among  the  unvacCinated,  but  a  large  number  of  vac- 

to  H.M.S.  Octavia,  Pari.  Papers,  House  of  Commons,  Sess. 
1866,  No.  278. 

*  In  former  epidemic  periods,  instances  of  the  disease  spread- 
ing extensively  aboard  ship  had  been  noticed — in  1825,  on 
board  the  Phaeton,  and  in  1836,  on  board  the  Hastings.  (See 
Rep.  of  Vacc.  Sec.  of  Prov.  Med.  Assoc,  p.  81.) 

j-  Inquiry  into  the  Causes  and  Effects,  etc.,  p.  64. 


2 TO  HANDBOOK  OF   VACCINATION. 

cinated  persons  also  contracted  the  disease ;  and  the 
mortality  of  post-vaccinal  small-pox,  as  treated  in  the 
Small-pox  Hospital,  was  99  per  cent,  of  the  cases,  in- 
stead of  the  usual  average  of  6'76  per  cent*  But  the 
proportion  of  deaths  also  from  natural  small-pox  in 
the  hospital  in  the  same  year,  instead  of  being  35  per 
cent,  of  the  cases,  mounted  to  47  per  cent.  So  that 
the  difference  was  due,  not  to  falling  off  in  the  prophy- 
lactic power  of  vaccination,  but  to  the  greater  intensity 
of  the  variolous  influence.  This  varying  intensity  of 
epidemic  influence  must  be  well  kept  in  mind.  From 
overlooking  it,  the  most  erroneous  conclusions  are  some- 
times drawn  as  to  the  decadence  of  the  protection  of 
vaccination.  Any  time  the  last  fifty  years  that  an  un- 
usually severe  epidemic  has  occurred,  there  have  been 
those  who  have  asserted  that  vaccination  was  wearing 
out.  It  was  said  as  much  fifty  years  ago  (in  the  epi- 
demic of  1818-19)  as  now.  Yet  the  records  of  the 
Small-pox  Hospital  for  1825  teach  the  same  lesson  as 
the  records  for  1863:  in  1825,  the  epidemic  being,  as 
Dr.  Gregory  stated,  unusually  malignant,  the  mortality 
in  the  hospital  of  post-vaccinal  cases  amounted  to  8 

*  Of  the  cases,  that  is,  taken  in  the  gross,  and  irrespective 
of  the  existence  of  marks  of  vaccination  or  of  the  quality  of 
the  vaccination.  By  deducting  cases  in  which  there  were  no 
cicatrices  of  vaccination,  the  death-rate  would  be  considerably 
reduced  both  on  the  average  of  years  (see  page  238)  and  in 
1863.  Among  the  thoroughly  vaccinated  patients  in  1863,  the 
death-rate  was  under  1  per  cent.;  only  three,  in  fact,  out  of 
123  deaths  that  took  place  from  small-pox  in  the  hospital  in 
that  year  in  persons  who  had  undergone  some  sort  of  vaccina- 
tion, being  in  persons  who  had  been  thoroughly  vaccinated. 
(See  Trans.  Epidem.  Soc,  vol.  ii.  part  1,  App.  containing  Ke- 
port  of  Small-pox  and  Vaccination  Committee,  1864.) 


PROTECTION  AGAINST  SMALL-POX.         2U 

per  cent.,  and  the  mortality  of  the  natural  disease  cor- 
respondingly rose  to  41  per  cent.* 

93 .  The  power  of  Vaccination  as  exhibited  by  ' '  pro- 
tected" classes  of  the  general  population. — The  an- 
nual Medical  Reports  of  the  British  Army  and  Navy, 
to  which  I  have  already  so  frequently  referred,  afford 
striking  proofs  of  the  protective  power  of  vaccination 
in  adult  populations,  exposed  to  the  ordinary  chances 
of  infection  of  the  countries  in  which  they  may  be  sta- 
tioned. The  troops  serving  in  the  United  Kingdom  may 
be  looked  on  as,  virtually,  a  wholly  "protected"  force, 
— for  since  1858  every  recruit,  whether  or  not  he  have 
marks  of  small-pox  or  of  previous  vaccination,  is  re- 
quired to  be  vaccinated  on  entering  the  service,  and 
the  soldiers  who  had  previously  enlisted,  who  were 
without  proper  marks  of  vaccination,  have  also  been 
ordered  to  be  revaccinated.  The  protection  of  the  men 
employed  in  the  navy  is  less  complete  than  that  of  the 
army;  partly,  apparently,  because  the  strict  rule  of 
the  service  that  all  who  have  not  marks  of  protection 
should  at  once  be  vaccinated  does  sometimes  get  evaded 
(page  258,  note),  and  partly  from  the  absence,  if  I 
am  not  misinformed,  of  a  rule  requiring  the  vaccination 
of  all  who  enter,  whether  previously  protected  or  not  ;f 

*  Paper  from  Hospital  for  Casual  Small-pox  and  Vaccina- 
tion in  Annual  Keport  of  the  Nat.  Vaccine  Board,  printed 
March  2,  1826. 

f  By  making  the  rule  absolute  to  vaccinate  every  person, 
whatever  his  marks  of  protection,  not  only  a  great  security  is 
obtained  against  errors  of  individual  judgment,  and  an  assur- 
ance provided  that  could  not  otherwise  have  been  had  that 
every  one  has  been  vaccinated,  but  a  large  majority  of  those 
subjected  to  the  rule  are  put  in  the  still  more  advantageous 


272  HANDBOOK  OF   VACCINATION. 

and  though,  relatively  to  the  number  of  men  employed, 
the  number  who  are  unprotected  is  exceedingly  small, 
the  presence  of  unprotected  persons  at  all  cannot  but 
affect  the  returns  whenever  small-pox  prevails,  and  will 
probably  account  in  chief  measure  for  the  different 
small-pox  liabilities,  particularly  as  regards  mortality, 
which,  as  we  shall  immediately  see,  the  two  services 
have.  In  upwards  of  nine-tenths  of  the  men  employed 
in  either  service,  the  protection  against  small-pox  is 
that  which  is  afforded  by  vaccination.*  Now,  if  we 
examine  the  records  of  these  services  to  see  what  havoc 
is  made  among  them  at  the  present  day  by  small-pox — 
the  disease  which,  according  to  Sir  G.  Blane,  was,  be- 
fore the  discovery  of  vaccination,  "one  of  the  greatest 
embarrassments  to  the  operations  of  armies,"  and 
obliged  ships  of  war  occasionally  to  quit  the  seasf — 
we  shall  find  that  on  the  average  of  the  six  years  1859 
-64,  notwithstanding  that  that  period  includes  two  se- 
vere epidemics,  the  annual  deaths  from  it  were  some- 
what less  than  1  per  10,000  among  the  soldiers,  and 
somewhat  more  than  2  per  10,000  among  the  sailors; 
that  the  cases  of  variolous  affection  of  any  kind  did  not 
exceed  annually  14  out  of  every  10,000  soldiers,  nor 
33  out  of  every  10,000  sailors;  the  disease  being  in 

position  of  having  been  revaccinated.  Even  this  simple  rule 
requires,  however,  I  believe,  a  good  deal  of  vigilance  to  see 
that  it  is  not  disregarded ;  and,  as  will  be  seen  by  the  note  to 
the  table  on  next  page,  individual  cases  may  now  and  then 
escape. 

*  See  note,  p.  231,  with  regard  to  the  proportion  of  the 
recruits  in  the  army  who  have  marks  of  previous  variola. 
As  the  navy  is  recruited  from  the  same  class  of  the  popula- 
tion, the  proportion  may  fairly  be  assumed  to  be  the  same. 

•f-  Med.-Chir.  Trans.,  vol.  x. 


PROTECTION  AGAINST  SMALL-POX. 


273 


the  great  majority  of  the  cases  exceedingly  modified. 
In  the  tables  which  I  subjoin,  showing  the  results  for 
each  force  and  for  each  year,  the  reader  will  not  fail  to 
note  the  effect  of  presence  or  absence  of  epidemic  in- 
fluence; and  as  it  happened  that  during  this  particular 
period  this  influence  was  present  in  the  unusual  pro- 
portion of  four  years  out  of  the  six,  the  average  of 
cases  and  deaths  is  unquestionably  largely  in  excess  of 
what  an  average  for  a  longer  period  would  give.* 

Table — showing  the  Cases  and  Deaths  from  Small-pox  among 
the  Troops  se7%vlng  in  the  United  Kingdom  for  Six  Years. 


Year. 

Number  of 
Troops. 

Cases  of 
Small-pox. 

Deaths. 

Ratio  per  10,000  of 
strength. 

Cases. 

Deaths. 

1859 

71,715 
85,443 
88,955 
78,173 
75,945 
73,252 

175 
140 
51 
64 
123 
111 

7 
9 
4 
4 
6 
10 

24-3 

16-8 

5-9 

8-1 

16-2 

151 

0-97 
105 
0-45 
0-51 
0-79 
1-36 

I860 

1801 

1862 

1863 

1864 

Totals .. 

473,483 

664f 

40 

14 

0-84 

*  The  publication  of  annual  returns  for  the  army  began 
only  with  1859:  those  for  the  navy  began  three  years  earlier. 
The  tables  are  for  corresponding  periods,  but  if  I  had  included 
in  the  table  for  the  navy  the  years  1856-8,  the  ratio  of  cases 
would  have  fallen  slightly  below  30  per  10,000 ;  and  of  deaths 
to  215. 

f  All  these  cases  were  in  men  who  had  vaccine  cicatrices, 
except  three  cases  (one  severe  and  two  mild),  in  1860,  in  men 
who  had  marks  of  previous  small-pox,  and  three  cases  (of 
24 


274 


HANDBOOK  OF   VACCINATION. 


In  the  navy,  if  we  except  the  remarkable  return  for 
1864,  to  the  circumstances  of  which  I  shall  have  occa- 
sion by  and  by  to  revert,  the  annual  average  number 
of  cases  would  only  be  20  per  10,000  as  compared  with 
14  per  10,000  in  the  army;  but  the  mortality  would 
still  (partly,  as  already  explained,  from  there  being  in 
the  force  some  who  were  not  vaccinated,  and  partly 
probably  from  the  less  extent  to  which  the  deficiencies 
of  primary  vaccination  had  been  supplemented  by  re- 
vaccination)  be  more  than  double. 

Table — showing  the  Cases  and  Deaths  from  Small-pox  in  the 
British  Navy  employed  on  the  uHome  Force"  for  Six  Years. 


Yeab. 

Mean 

Strength. 

Cases  of 
Small-pox. 

Deaths. 

Ratio  per  10,000  of 
strength. 

Cases. 

Deaths. 

1859 

19,300 
23,500 
22,900 
20,760 
21,570 
19,630 

51 
84 
35 
8 
39 
199 

4 

12 
1 
1 

2 
9 

26-4 
35-7 
153 
3-8 
18-0 
101-0 

2-1 

51 

0-43 

0-48 

0-97 

4-0 

1860 

1861 

1862 :..... 

1863 

1864 

Totals 

127,660 

416 

29 

33 

2.3 

These  returns,  satisfactory  as  in  many  respects  they 
are,  are  much  less  so  than  we  may  hope  to  receive  a 
few  years  hence,  when  the  general  population  of  the 
kingdom  shall  have  received,  in  place  of  the  slipshod 
vaccination  heretofore  too  frequently  practiced,  the  kind 


which  two  were  fatal),  in  the  same  year,  in  men  who  had  no 
satisfactory  marks  either  of  small-pox  or  of  vaccination. 


PROTECTION  AGAINST  SMALL-POX.         275 

of  vaccination  necessary  for  full  protection  ;*  and  when 
the  revaccination  of  the  services  shall  have  been  com- 
pletely carried  out. 

In  younger  classes  of  the  population  the  evidence  of 
protection  is  still  more  striking.  In  the  Royal  Military 
Asylum  there  has  been  no  fatal  case  of  small-pox  among 
the  many  thousand  vaccinated  children  admitted  since 
its  institution  in  1803 :  four  deaths  from  small-pox  there 
have  been  in  the  asylum,  but  they  were  all  in  children 
who,  being  believed  to  have  already  had  small-pox,  had 
not  been  vaccinated,  f  Among  an  annual  average  of 
550  boys  in  Christ's  Hospital  there  occurred,  during 
the  last  half  of  last  century,  thirty-one  deaths  from 
small-pox ;  among  an  annual  average  of  800  boys  there 
was,  during  the  first  half  of  this  century,  but  one  death 
from  this  cause — a  death  which  occurred  in  the  year 
I880.| 

94.  The  Protective  Power  of  Vaccination  extends 
to  all  Climates. — The  protective  power  of  vaccination 
against  small-pox  extends  to  every  race  of  mankind, 
and  is  exhibited  in  every  climate  and  in  every  part  of 
the  habitable  globe.  Natural  small-pox,  severe  and 
fatal  as  it  is  in  Europe,  is.frecmently  a  much  more 

*  The  vaccination  that  men  entering  the  army,  navy,  etc. 
have  previously  received  is,  of  course,  the  current  vaccination 
of  the  country,  and  we  do  not  know  how  many  of  the  fatal 
small-pox  cases  were  in  men  who  had  only  the  one,  two,  or 
three  marks  insufficient  for  full  protection.  It  would  be  very 
desirable  if  in  all  cases  of  post-vaecinal  small-pox,  in  both 
services,  the  number  and  the  quality  of  the  vaccine  marks 
were  noted. 

f  T.  G.  Balfour,  Medico-Chir.  Trans.,  vol.  xxxv. 

%  Communication  from  Mr.  Stone:  Papers  relating,  etc. 
(op.  cit.),  p.  153. 


276  BANDBOOK  OF   VACCINATION. 

severe  and  fatal  disease  in  tropical  climates  and  among 
dark  races.  But,  relatively  to  this  greater  severity, 
vaccination  appears  to  be  in  them  fully  as  protective. 
A  person  vaccinated  in  a  temperate  climate  may  some- 
times, there  is  reason  to  believe,  by  change  to  a  trop- 
ical climate,  become  somewhat  more  liable  to  small-pox 
(§  92,  d) ;  but  a  person  vaccinated  in  India,  and  remain- 
ing in  India,  if  the  course  of  his  vaccination  have  been 
regular,  is  probably  just  as  safe  relatively  as  a  person 
vaccinated  in  England.  "  It  is  the  opinion  of  every 
medical  man  we  have  consulted,"  say  the  Small-pox 
Commissioners  appointed  by  the  Indian  Government  in 
1850,  "  and  we  believe  it  is  that  of  every  educated  man 
in  India,  that  when  properly  and  successfully  con- 
ducted, vaccination  is  just  as  efficient  a  safeguard  here 
as  it  is  in  England."*  Sixteen  medical  correspondents 
of  the  Epidemiological  Society  in  India,  dependent  all 
of  them  on  vaccination  for  their  protection  against 
small-pox,  had  been,  with  two  exceptions,  greatly  ex- 
posed to  its  infection,  some  of  them  almost  living  for  a 
length  of  time  in  variolated  atmospheres,  but  none  of 
them  had  ever  taken  it.  As  in  the  East  Indies,  so  also 
in  Ceylon,  in  the  Mauritius,  in  the  West  Indies,  on  the 
West  Coast  of  Africa,  in  Brazil,  and  other  similar  cli- 
mates, whenever  small-pox  has  prevailed,  exemption 
from  attack  has  been  the  rule  among  the  vaccinated, 
the  rare  exception  among  the  unvaccinated,  population; 
and  the  disease,  if  contracted  by  the  vaccinated,  has 
put  on  precisely  the  same  kind  of  modifications  that 
have  been  noticed  in  Europe.  But  in  tropical  climates 
there  are  sometimes  difficulties  in  keeping  up  supplies 

*  Report  of  the  Small-pox  Commissioners  [op.  eit.),  p.  41. 


PROTECTION  AGAINST  SMALL-POX. 


277 


of  active  vaccine  lymph  (§  39)  at  certain  seasons  of  the 
year,  which  render  attention  even  more  necessary  there 
than  here  to  ascertain  that  the  vaccinations  performed 
have  been  really  genuine  and  effective.  Whenever  an 
apparently  high  rate  of  post-vaccinal  small-pox  mor- 
tality has  obtained,  investigation  has  never  failed  to 
show  that  there  has  been  defect  in  the  quality  of  the 
vaccination.  This  was  well  ascertained  by  Dr.  Kinnis 
in  the  very  interesting  and  instructive  inquiries  he 
made  into  the  circumstances  of  two  epidemics  in  Cey- 
lon (the  two  first  of  the  epidemics  included  in  the  fol- 
lowing table),  in  both  of  which  epidemic  influence  must, 
judging  from  the  high  death-rate  of  the  cases  of  the 
natural  disease,  have  been  very  intense. 


Epidemic. 

Natural  Small-pox. 

Second  Small-pox. 

Post-  vaccinal 
Small-pox. 

I 

a 
ft 

*  J:  m 

u   SS  * 
C.QO 

So** 

ss 

08 

■ 
ft 

c  m 

Z  -Z  as 
a.ftO 

3° 

I 

§5  8 
SIS 

CftO 

M 

Ceylon  (1830) 

Ceylon  (18*3-4).... 
Mauritius  (1840-1) 
Jamaica  (1851-2).. 

123 

228 
281 
477 

58 
88 
120 
75 

47 
38-5 
42-7 
16 

4 

2 

2 

1«9 
197- 
421 
120 

34 

21 

30 

4 

18 
10-6 

7 

3-33 

11 

2 

In  reference  to  the  first  of  the  Ceylon  epidemics,  it 
was  found,  on  inquiry,  that  out  of  the  189  cases  of  al- 
leged post-vaccinal  small-pox,  there  was  in  56,  including 
18  of  the  fatal  cases,  not  the  slightest  evidence  what- 
ever that  vaccination  had  at  anytime  been  successfully 
performed ;  and  that,  of  the  lb3  remaining  cases,  57, 
with.  15  deaths,  were  among  persons  whose  marks  of 
vaccination  were  unsatisfactory,  "  not  such  as  are  left 
24* 


278  HANDBOOK  OF   VACCINATION. 

by  vaccination  when  undisturbed  in  its  course :  while 
in  those  (76)  who  had  good  marks  of  vaccination,  the 
disease  was  rendered  so  mild  that  only  one  died."  In 
the  other  Ceylon  epidemic,  of  the  197  professedly  vac- 
cinated persons  who  contracted  small-pox,  86,  includ- 
ing 19  of  the  21  fatal  cases,  had  either  no  marks  at 
all  of  vaccination,  or  marks  which  were  not  satisfactory, 
and  only  2  deaths  took  place  among  the  111  cases  in 
which  there  were  genuine  vaccine  marks  *  And  in 
the  interesting  account  which  Mr.  Gardner  has  given 
of  the  Mauritius  epidemic,  it  is  stated  that  in  13  only 
of  the  30  deaths  alleged  to  have  occurred  from  post- 
vaccinal small-pox,  were  the  evidences  of  vaccination 
satisfactory,  f 

Among  the  native  soldiers  in  India,  whose  wives 
and  families  are  frequently  the  subjects  of  virulent  and 
fatal  small-pox,  the  protection  resulting  from  the  vac- 
cination to  which  the  regulations  of  the  service  have 
obliged  the  soldiers  themselves  to  submit,  is  most 
strikingly  seen.  The  ratio,  also,  of  small-pox  cases 
occurring  in  the  European  troops  stationed  in  India, 
from  1860  to  1864  inclusive,  as  exhibited  in  the  fol- 
lowing table,  though  somewhat  higher  than  that  no- 
ticed among  the  troops  stationed  in  the  United  King- 
dom (p.  273),  is  not  more  so  than  is  explicable  by  the 
greater  and  more  frequent  exposure  to  which  they  are 
liable  in  some  of  the  stations  in  India  to  the  specific 
cause  of  the  disease ;  the  greater  relative  mortality  is 
due,  probably,  partly  to  vaccination  having  in  a  few 

*  Kinnis,  Keport  on  Small-pox  as  it  appeared  in  Ceylon,  etc. 
8vo.  Columbo,  1835. 
•j-  Seaton,  op.  cit.,  p.  355. 


PROTECTION  AGAINST  SMALL-POX. 


279 


cases  been  omitted,  or  not  repeated  in  cases  in  which 
the  marks  were  imperfect,  and  partly  to  the  influence 
of  climatic  change. 


Province. 

Aggregate 
strength 
(5  years). 

Cases  of 
Small- 
pox. 

Deaths 
from 

Small- 
pox. 

Annual  ratio  per 
10,000  of  strength. 

Cases. 

Deaths 

201,677 
59,580 
56,620 

482 
31 
101 

71 
4 
15 

24 
5-2 

17-8 

3-55 
0-67 
2-65 

Total 

317,877 

614 

90 

19-2 

2-83 

The  valuable  statistics  which  Mr.  Leith  has  pub- 
lished respecting  the  Island  of  Bombay,  show  that  for 
the  five  years  1848-53,  the  small-pox  deaths  among  the 
general  population,  the  majority  of  which  is  unpro- 
tected, were  5-8  per  cent,  of  the  mortality  from  all 
causes — about  two-thirds  the  rate  which  used  to  pre- 
vail in  England  before  the  discovery  of  vaccination : 
but  among  the  European  community  on  the  island, 
which  is,  with  comparatively  few  exceptions,  protected 
by  vaccination,  the  small-pox  deaths  were  for  the  same 
period  only  1  per  cent,  of  the  deaths  from  all  causes.* 

95.  The  Protective  Power  of  Vaccination  shown 
in  National  Statistics  of  Small-pox. — In  consequence 
of  the  remarkable  power  of  vaccination  in  protecting 
against  small-pox,  and  the  adoption  of  the  practice 
universally  by  educated  people  and  in  annually  in- 
creasing proportion  by  the  population  at  large,  the 
present  average  death-rate  from  small-pox  is  scarcely 

*  Morehcad's  Researches  on  Disease  in  Tndia,  vol.  i.  chap.  v. 


280  HANDBOOK  OF   VACCINATION. 

in  any  European  country  one-tenth  part,  and  in  those 
countries  in  which  vaccination  has  been  most  carefully 
carried  out,  it  is  much  less  than  one-tenth  part,  what 
it  was  at  the  end  of  the  last  century.  Thus  in  Sweden, 
where,  before  vaccination  was  discovered,  the  average 
annual  death-rate  from  small-pox  was  2050  out  of 
every  million  of  population,  during  the  forty  years, 
1810-50,  it  was  but  158;  in  Westphalia,  where  the 
small-pox  death-rate  used  to  be  2643  per  million,  it 
was  from  1816-50  only  114;  in  Bohemia,  Moravia, 
and  Austrian  Silesia,  it  has  been  reduced,  in  like  man- 
ner, from  4000  to  200;  in  Copenhagen,  from  3128  to 
286  ;  and  in  Berlin,  from  3422  to  176.  Especially  in- 
teresting is  it  to  review  what  has  been  done  in  our 
own  country,  and  to  contrast  with  the  3000  annual 
deaths  from  small-pox  per  million  of  population  in 
England — the  estimated  death-rate  at  the  end  of  the 
last  century — the  present  death-rate  from  the  same 
cause,  amounting  only  to  two  hundred  per  million; 
or  with  the  1780  average  annual  deaths  which  took 
place  from  small-pox,  in  London,  within  the  bills  of 
mortality,  between  the  years  1790  and  1800,  on  a 
population  little  exceeding  a  quarter  of  a  million,  the 
759  deaths  which  have  been  the  annual  average  of  the 
last  thirteen  years,  in  our  present  London,  containing 
more  than  ten  times  the  population.*     If  the  reader 

*  And  this,  notwithstanding  the  intensity  of  epidemic  in- 
fluence manifested  in  some  of  these  years  [vide  ante,  p.  270). 
It  will  he  seen  that  small -pox  prevailed  epidemically  in 
London  in  five,  if  not  in  six,  out  of  these  thirteen  years.  In 
this  vast  metropolis,  with  its  two  thousand  hirths  a  week, 
the  law  wTith  regard  to  early  infantile  vaccination  requires 
to   be   administered   in   its   utmost    strictness   to   give   any- 


PROTECTION  AGAINST  SMALL-POX.         281 

will  examine  these  tables,  first  year  by  year,  and 
then  for  series  of  years,  he  will  see  that,  when  the 
disturbing  influence  of  epidemic  prevalence  in  special 
years  is  got  rid  of,  by  taking  the  years  not  one  by 
one,  but  in  groups,  each  group  comprising  epidemic 
and  non-epidemic  years,  the  decline  of  small-pox  mor- 
tality exhibits  a  regular  progression,  in  correspond- 
ence with  the  progress  that  has  been  made  in  the 
adoption  of  vaccination.  This  is  seen  at  a  glance  from 
the  following  summary : 

thing  like  reasonable  security  against  frequently  recurrent 
epidemics  of  small-pox.  A3  it  has  been  heretofore  adminis- 
tered, scarcely  ever  more  than  two  years  together  have  passed 
without  an  epidemic  visitation.  "Whatever  may  be  the  various 
circumstances,  some  of  them  unknown  to  us,  which  determine 
why  diseases  like  small-pox,  scarlatina,  measles,  etc.  should 
be  epidemic  at  one  time  and  not  at  another,  the  aggregation  of 
susceptible  individuals  is  assuredly  one  of  the  most  influential 
circumstances  in  determining  the  frequency  of  recurrence.  In 
this  we  have  the  most  rational  explanation  why,  the  observ- 
ance of  infantile  vaccination  being  about  the  same,  London 
should  have  epidemics  of  small-pox  every  two  years  or  there- 
abouts, while  Liverpool  or  Birmingham  may  remain  five,  six, 
or  seven  years  without  an  epidemic  visitation,  and  other 
smaller  towns  a  much  longer  time.  But  take  smaller  towns 
in  which  infantile  vaccination  is  much  more  neglected  than 
in  the  foregoing — such  towns,  for  instance,  as  Northampton — 
and  we  find  epidemics  recurring  more  frequently  than  in 
Liverpool  or  Birmingham.  In  Northampton  (the  like  of 
which  for  scandalous  neglect  of  vaccination  it  would  be  diffi- 
cult to  find  in  England),  though  its  population  little  exceeds 
40,000,  there  were  very  fatal  and  wide  epidemics  of  small-pox 
in  1856,  in  1860,  and  in  1865. 


282 


HANDBOOK  OF    VACCINATION. 


Periods  compared. 

Annual 
Deaths  by 
Small-pox 
inKnirhind 
and  Wales. 

Annual 
rate  per 
million  of 
the  Popu- 
lation. 

1.  Average  of  thirty  years  previous  to  introduction  of 
Vaccination,  estimated  by  Dr.  Lettsom  and  Sir 
Gilbert  Blane 

3000 

770 
304 
202 

2.  Average  of  three  years  (1838—10),*  when  Vaccination 
had  become  to  a  great  extent  diffused,  but  before 
any  public  provision  was  made  for  its  gratuitous 

11,944 
5,221 
3,967 

3.  Average  of  ninef  of  the  years  (1841-53)  when  pub- 
lic Vaccination  was  gratuitously  provided,  but 

4.  Average  of  the  twelve  years  (1854-65)  during  which 
Vaccination  has  been  to  a  certain  extent  obliga- 

The  Registrar-General  of  England,  in  his  most  re- 
cent report, |  states  some  facts  which  put  in  a  very 
strong  light  the  beneficial  results  which  have  been  ob- 
tained from  the  increased  ohservance  of  vaccination  in 
England,  consequent  on  the  compulsory  Vaccination 
Act  of  1853,  imperfect  as  that  act  was,  and  imper- 
fectly as  it  has  been  administered.  His  figures  show 
that,  on  comparing  the  mortality  of  the  kingdom  from 
all  causes  during  the  last  of  the  periods  in  the  above 
table  with  the  period  immediately  preceding,  there  had 
been  an  annual  gain  of  life  of  31  per  100  000  of  popu- 
lation, and  that  one-third  of  this  gain  had  been  from 
small-pox  alone.  Comparing  also  the  mortality  from 
all  causes  in  London  for  thirteen  years  immediately 
preceding,  and  thirteen  years  immediately  following 
that  act,  it  appeared  that  during  the  latter  period  six- 


*  Eegistration  of  the  deaths  in  England  began  only  in  1837. 
f  During  the  years  1843-46  the  causes  of  death  were  not 
analyzed  in  the  Keports  of  the  Kegistrar-General. 
%  Twenty-eighth  Annual  Keport,  for  the  year  1865. 


PROTECTION  AGAINST  SMALL-POX.        283 

teen  lives  had  been  saved  every  year  out  of  every 
100,000  of  the  population,  and  that  ten  of  the  lives  so 
saved,  or  nearly  two-thirds  of  the  total  gain,  had  been 
from  small-pox.  The  annual  mortality  from  all  causes 
in  London  was,  in  the  two  periods,  2447  and  2431 
per  100,000  living,  respectively;  the  annual  mortality 
from  small-pox,  38  and  28  per  100,000  living,  respect- 
ively. Small-pox — which  in  England  thirty  years  ago 
was,  in  one  of  its  years  of  epidemic  prevalence,  the 
fifth  most  fatal  disease — has,  in  the  worst  epidemic 
that  has  occurred  in  the  last  twelve  years,  occupied  no 
higher  than  the  eighteenth  place  among  the  causes  of 
death,  as  arranged  by  the  Registrar-General. 

The  time  which  has  elapsed  since  compulsory  vac- 
cination was  extended  to  Scotland  has  been  far  too 
short  to  enable  us  to  form  any  complete  judgment  of 
its  results  in  that  portion  of  the  kingdom.  It  was  not 
till  the  middle  of  1864  that  it  began  to  take  effect ;  and 
though  there  has  been  since  then  an  extraordinary 
diminution  in  the  small-pox  mortality,  the  connection 
of  which  with  the  increased  observance  of  vaccination 
cannot  be  doubted,  an  average  of  many  years  must  be 
awaited  before  the  full  extent  of  the  benefits  to  be  de- 
rived from  it  can  be  ascertained.  The  average  annual 
small-pox  mortality  of  the  ten  years,  1855-64,  was 
1054,  or  366  deaths  per  million  of  population.*  The 
total  deaths  from  small-pox  in  1865  were  123,  and  in 
1866,  280;  or  39  and  88  per  million  of  population, 
respectively.  In  no  two  previous  years  is  there  any 
record  of  the  small-pox  mortality  being  so  low. 


*  Tenth  Detailed  Annual  Report  of  Registrar-General  for 
Seotland. 


284 


HANDBOOK  OF   VACCINATION. 


96.  Theory  of  Decadence  of  Vaccine  Power. — This 

progressive  decline  of  small-pox  as  vaccination  has  ad- 
vanced, affords  but  little  countenance  to  the  theory 
that  has  at  times  been  propounded,  that  the  protective 
power  of  vaccination  over  populations  is  wearing  out.* 
The  very  precise  statistics  of  the  army  are  equally  at 
variance  with  it.  If  we  compare  the  number  of  cases 
of,  and  the  mortality  from,  small-pox  now,  with  what 
these  were  from  thirty  to  twenty  years  ago,  we  find 
there  has  been  a  very  remarkable  diminution : 


Troops  serving  in  the 

Uuited  Kingdom 

during  the 

undermentioned  years. 

Aggregate 
Strength. 

Cases  of 
Small- 
pox. 

Deaths  by 
Small- 
pox. 

Annual  Ratio  per 
10,000  of  strength. 

Cases. 

Deaths. 

2-20 
0-84 

1837-1846f 

254,597 
473,483 

557 
664 

56 
40 

21-88 
14-0 

1859  1864J 

The  small-pox  mortality,  in  fact,  of  the  worst  epidemic 
year  of  the  latter  period  (1  36  per  10,000  troops — see 
table,  page  273)  is  far  short  of  the  average  of  the  pe- 
riod 1837-46.  Yet  the  army  is  far  more  dependent 
on  vaccination  for  its  protection  now,  than  it  was  thirty 
or  twenty  years  ago  (see  note,  p.  231).  The  gain, 
in  fact,  is  wholly  due  to  the  means  which  have  been 
taken  in  these  latter  years  to  make  the  protection  by 


*  The  facts  on  which  principally-  this  hypothesis  has  heen 
hased  have  (as  already  stated)  quite  another  explanation 
(2  92,  f). 

•}•  T.  G.  Balfour  on  the  Protection  against  Small-pox,  etc., 
in  Medico-Chir.  Trans.,  vol.  xxx'v. 

J  Annual  Statistical,  Medical,  and  Sanitary  Eeports  of  the 
Army,  commenced  in  1859. 


PROTECTION  AGAINST  SMALL- POX.         285 

vaccination  more  perfect  (§  93).  It  has  been  already 
seen  (Chapter  X  )  that,  with  due  care,  vaccine  lymph 
loses  nothing  of  its  essential  properties,  so  far  as  its 
immediate  effects  on  the  human  system  are  concerned, 
by  successive  transmissions  through  the  human  sub- 
ject ;  and,  from  this  fact  alone,  it  would  be  a  fair  in- 
ference that  it  loses  nothing  of  its  prophylactic  power. 
But  the  matter  has  been  repeatedly  put  to  experiment. 
Sacco,  in  1825  (for  the  theory  of  decadence  had  its  ad- 
vocates then  as  it  has  now),  performed  variolous  inoc- 
ulation on  a  number  of  subjects  who  had  been  vaccin- 
ated two  years  before,  with  the  then  current  lymph, 
i.e.  with  lymph  that  had  been  upwards  of  twenty-three 
years  in  use,  and  at  the  same  time  on  a  number  of 
other  subjects  who  had  been  vaccinated  twenty,  twenty- 
two,  and  twenty-four  years  before,  or  with  lymph  only 
a  very  few  removes  from  the  cow :  in  each  class  of 
subjects  the  results  were  the  same,  and  were  local  only.* 
Similar  variolous  testings  in  England,  previous  to  the 
time  when  the  variolous  inoculation  of  human  subjects 
was  made  illegal,  gave  precisely  similar  results,  f  But, 
in  truth,  we  have  experiments  on  a  much  larger  scale 
made  to  hand  in  every  epidemic  of  small-pox  that  oc- 
curs. In  each  such  epidemic — no  matter  at  what 
epoch  since  the  introduction  of  the  practice  of  vaccina- 
tion— it  has  not  been  the  persons  vaccinated  with  the 
then  current  lymph,  the  lymph  farthest  from  the  cow, 
but  those  vaccinated  some  sixteen,  twenty,  or  twenty- 
five  years  before,  with  lymph  so  much  the  nearer  to 

*  Sacco,  Do  Vaccinat.  Necessitate,  Mediol.  1832. 
f  See  for  examples  pages  208,  note,  and  2G3,  note. 
25 


286  HANDBOOK  OF   VACCINATION. 

the  parent  source,  who  have  been  found  to  be  the  chief 
sufferers  from  postvaccinal  small-pox. 

97.  Evidence  that  the  present  Small-pox  mortality 
in  England  is  due  to  Neglect  of  Vaccination  and  to 
its  Inefficient  Performance. — But,  if  vaccination  can 
so  control  small-pox,  how  comes  it  that  there  should 
be  still,  as  on  the  average  of  the  last  ten  years  there 
have  been,  above  4000  deaths  a  year  from  this  cause 
in  England  ?  First  and  chiefly,  because  vaccination  is 
still  largely  neglected  ;  and  secondly,  because  in  many 
cases  it  has  been  inefficiently  performed.  That  these 
are  the  real  causes,  is  provable  in  two  ways :  (a)  from 
analysis  of  the  death  returns,  and  (b)  from  the  results 
of  special  inquiries. 

(a)  From  Analysis  of  the  Death-returns. — If  the 
reader  will  refer  to  the  deaths  from  small-pox  Avhich 
take  place  in  England,  he  will  see  at  a  glance  that 
seven-tenths  of  this  mortality  is  in  children  under 
puberty,  at  a  time  of  life  when  the  power  of  vaccina- 
tion, even  of  such  vaccination  as  results  only  in  a  sin- 
gle characteristic  vesicle,  to  save  from  death  by  small- 
pox is  quite  indisputable.  In  the  whole,  therefore,  of 
the  mortality,  or  about  3000  out  of  the  annual  4227 
deaths,  the  non-performance  of  successful  vaccination 
may,  with  rare  exceptions  in  individual  cases,  be  prop- 
erly assumed.  Of  the  .remaining  1200  annual  deaths 
or  thereabouts — the  deaths  after  puberty — there  are  no 
means  of  knowing  in  how  many  of  the  subjects  vac- 
cination had  been  performed,  or  in  how  many  not ;  we 
should  probably  little  err  if  we  stated  that  not  nearly 
the  half  of  them  had  been  vaccinated,  but  for  our  pres- 
ent purpose  we  may;  if  we  like,  assume  that  the  whole 
had  been,  as  it  is  called,  vaccinated — and  the  question 


PROTECTION  AGAINST  SMALLPOX.         287 

would  then  arise,  in  ivhat  manner  had  the  vaccination 
been  done  ?  This  point,  as  regards  the  individuals, 
cannot  of  course  be  ascertained.  But  we  may  fairly 
apply  to  the  group  the  observations  made  for  twenty 
years  in  the  Small-pox  Hospital  on  fatal  cases  of  small- 
pox in  individuals  believed  to  have  been  successfully 
vaccinated.  Of  the  total  number  of  402  such  fatal 
cases,  101  exhibited  on  their  arms  no  evidence  what- 
ever of  having  ever  had  effective  vaccination  ;  2*7*7  had 
but  one  or  two  vaccine  marks,  and  these  in  191  of  them 
were  of  imperfect  character  ;  16  were  in  persons  who 
had  three  cicatrices ;  and  only  5  in  persons  who  had 
been  vaccinated  in  the  way  that  has  been  shown  to  be 
the  most  protective, — of  which  5  two  did  not  die  of  the 
small-pox,  but  of  concurrent  or  superadded  disease.* 
Only  one,  then,  in  80  of  these  fatal  cases  among  the 
vaccinated,  occurred  in  patients  who  had  been  vaccin- 
ated in  the  best  way.  Such  facts  can  leave  no  doubt 
on  the  mind  of  any  reasonable  being,  that  the  1200 
adults  who  die  on  an  average  every  year  in  England 
from  small-pox  can  either  not  have  had  vaccination 
performed  at  all,  or  must,  with  few  exceptions,  have 
had  it  very  imperfectly  done,  and  must  have  taken  no 
after-steps  to  remedy  the  imperfection. 

(b)  From  the  Results  of  Special  Inquiries. — From 
the  official  inquiry  into  the  state  of  vaccination  in 
England  made  from  1860  to  1864,  under  the  direction 
of  the  Privy  Council,  it  appears  that  the  districts  into 
which  the  kingdom  is  divided  for  the  purpose  of  public 

*  Marson,  art.  "Small-pox,  etc.  (op.  cit.),  p.  473.  These 
five  deaths  occurred  among  544  patients,  who,  having  been 
properly  vaccinated,  had  most  of  them  the  small-pox  in  its 
light  or  varicelloid  form  only. 


238  HANDBOOK  OF   VACCINATION. 

vaccination  exhibit  every  shade  of  variety  as  to  the 
extent  to  which  vaccination  is  carried  out, — from  com- 
plete observance  of  the  law,  to  the  most  culpable  and 
reckless  disregard  of  it.  In  numerous  districts  infan- 
tile vaccination  was  found  to  be  carried  out  either  com- 
pletely, or  with  such  trivial  delay  as  could  readily  be 
overtaken  at  the  slightest  alarm  ;  and  in  all  these  dis- 
tricts not  only  did  the  death-registers  show  absence 
of  small-pox  mortality  of  the  native  population,  but  the 
disease  itself  had  never  made  any  serious  lodgment, 
had  never  to  any  extent  spread.  With  scores  of  such 
districts  I  am  myself  acquainted,  districts  in  which, 
although  the  population  has  been  exposed  again  and 
again  to  the  infection  of  small-pox,  the  disease  prevail- 
ing all  around  them,  and  being  frequently  imported 
into  them,  the  utmost  suffering  of  the  native  population 
has  yet  been  the  occurrence  of  a  few  modified  cases  of 
it,  here  and  there,  without  any  extension.  The  type 
of  such  a  district  is  that  of  Mold,  in  the  Holywell 
Union,  Flintshire.  It  is  a  district  comprising  a  popula- 
tion of  nearly  16,000  persons,  partly  mining  and  partly 
agricultural,  which,  since  the  passing  of  the  Compul- 
sory "Vaccination  Act  of  1853,  has  been  kept  completely 
vaccinated.  It  is  a  district  greatly  exposed  to  small- 
pox, not  only  from  adjacent  districts,  but  from  its  con- 
stant communication  with  Liverpool.  In  the  fourteen 
years  which  have  passed  since  1853,  small-pox  has  pre- 
vailed on  various  occasions  all  round  it.  At  such  times 
the  disease  has  been  imported  into  it  again  and  again. 
During  the  epidemic  of  small-pox  that  pervaded  Eng- 
land in  1858-9,  there  were  repeated  importations ;  in 
1864,  there  were  at  least  thirty  distinct  importations, 
chiefly  from  Liverpool,  and  there   were   several  fatal 


PROTECTION  AGAINST  SMALL-POX. 


289 


cases  within  the  district  in  persons  who  were  strangers 
But  the  utmost  suffering  of  the  native  population  or 
among  the  regular  inhabitants  of  the  district,  in  the 
whole  fourteen  years,  was  four  cases  of  natural  small- 
pox in  children  who  had  not  passed  the  period  lawfully 
allowed  for  the  performance  of  vaccination;  a  fifth 
(fatal)  case  in  a  child  born  with  the  disease,  its  mother 
having  modified  small-pox  at  the  time  of  her  confine- 
ment; and  a  few  modified  cases  in  persons  who  came 
directly  in  contact  with  the  imported  cases.  Beyond 
the  points  of  importation  the  disease  has  never  spread.* 


*  Dr.  Hughes,  of  Mold,  who  was  the  Public  Vaccinator  of 
the  district  during  the  whole  of  this  period,  and  to  whose 
exertions  these  great  results  are  due,  has  been  kind  enough  to 
furnish  me  with  the  complete  statistics  of  vaccination  in  the 
district  from  the  date  of  the  Compulsory  Act  to  September 
30,  1867,  as  under : 


Period. 

id 

Hi  o 

^  c 

|| 

si 

I*5 

Certified  as 
successfully 

Vaccinated. 

s 
c 
'>   , 

S-.2 
1.1 

•5  -5 

V 

n3 

o 

il 
'>  * 

.-  ~ 

5 

3 

_o 
'?    . 

ELg 

H 
-  * 

IS 

I 

Not 
Vaccinated. 

—  - 

Si 

■ 

-*  o 

o  to 

IS 

lit 

-   =  i- 

^  Oto 

13  years  ending  Sept.  30, 
1S66 

6925 
729 

5784 
454 

324 
63 

202 
22 

600 
54 

4 

11 
61 

Year    ending    Sept.    30, 
1867 

85 

Total  14  years.... 

7654 

6238 

377 

224 

654 

4 

72 

85 

It  will  be  seen  that  there  were  at  the  time  of  this  return  only- 
eleven  postponed  vaccinations  of  children  whose  births  were 
registered  before  September  30,  1866  :  ten  of  these  eleven 
were  children  registered  in  the  year  ending  September  30, 
25* 


290  HANDBOOK  OF   VACCINATION. 

In  some  districts  of  this  kind,  in  which  the  younger 
population  were  all  duly  vaccinated,  but  in  which  the 
elder  children,  who  had  been  born  before  the  enact- 
ment of  the  compulsory  law,  and  who  were  therefore 
exempt  from  its  provisions,  had  remained,  many  of 
them,  unvaccinated,  the  first  epidemic  of  small-pox 
which  swept  over  the  districts  after  the  passing  of  that 
law  had  laid  hold  of  the  latter;  and  very  singular  it 
was  to  note  how,  under  these  circumstances,  the 
usual  distribution  of  small-pox  deaths,  with  regard  to 
the  age  of  the  patients,  had  been  reversed ;  instead  of 
more  than  half  the  mortality  being  in  children  under 
five  years  old,  there  were  under  that  age  no  deatks  at 
all,  or  but  an  occasional  death  recorded,  the  mortality 
being  altogether  of  elder  children,  adolescents,  and 
adults.  Such  were  the  districts  at  one  end  of  the 
scale — districts  which  kept  small-pox  at  bay — not  actu- 
ally few  in  number,  but  still  in  small  proportion  to  the 
total  districts  of  England ;  for,  taking  the  kingdom 
throughout,  neglect  of  early  vaccination,  of  more  or 
less  serious  amount,  was  found  to  be  the  rule  and  not 
the   exception.*     To  such   neglect  anything  beyond 

1866.  Dr.  Hughes  adds,  "  No  child  born  in  the  Mold  district, 
and  alive  at  the  date  of  the  registration  of  its  birth,  has  died 
of  small-pox  during  the  fourteen  years.  One  infant,  whose 
mother  was  ill  of  varioloid  disease  at  its  birth,  died  of  small- 
pox when  four  or  five  days  old."  (See  further  interesting  par- 
ticulars on  this  district  in  Brit.  Med.  Journ.,  May  11,  1867.) 

*  In  the  Keport  of  the  Vaccination  Section  of  the  Provin- 
cial Medical  and  Surgical  Association,  1839,  and  in  the  Report 
of  the  Small-pox  and  Vaccination  Committee  of  the  Epidemi- 
ological Society,  1853,  the  reader  will  find  interesting  ac- 
counts of  the  state  of  vaccination  in  England  at  those  periods 
respectively.     Great  progress  bad  been  made  since  then. 


PROTECTION  AGAINST  SMALL-POX.         291 

mere  casual  small-pox  mortality  was  always  traceable. 
In  very  many  districts  this  neglect  had  been  allowed  to 
go  on  accumulating  till  it  assumed  considerable,  and  in 
some  really  enormous  proportions ;  and  these  specially 
neglected  districts  not  only  themselves  contribute  most 
unduly  to  the  large  small-pox  mortality  of  the  kingdom, 
but  are  the  means  of  spreading  the  disease  broadcast. 
This  was  strikingly  illustrated  in  the  great  epidemic  of 
small-pox  that  set  in  while  the  inquiry  was  in  progress. 
The  places  in  which,  in  1864-5,  there  was  a  very  high 
rate  of  small-pox  mortality,  were  all  of  them  places  in 
which  there  had  been  the  most  scandalous  neglect  of 
vaccination  ;  and  except  in  the  very  few  of  them  which 
the  inquiry  had  not  reached  till  the  epidemic  was  already 
prevailing,  the  local  authorities  of  each  place  had  been 
warned  beforehand  of  that  neglect  and  of  its  inevitable 
consequences,  but  had  not  thought  fit  to  take  proper 
steps  to  remedy  it.  Of  the  7684  deaths  from  small- 
pox in  England  in  1864,  648,  or  a  twelfth  part  of  the 
whole,  occurred  in  2  out  of  the  641  Registration  Unions 
into  which  England  is  divided :  two  unions,  in  which 
the  unvaccinated  children  literally  amounted  to  thou- 
sands. They  were  the  Union  of  Dudley,  with  a  popu- 
lation of  130,267,  in  which  420  deaths  from  small-pox 
were  registered  ;  and  the  Union  of  Portsea  Island 
(Portsmouth  and  its  suburbs),  with  a  population  of 
94,828,  in  which  there  were  228  deaths  from  small-pox. 
And  each  of  these  places  was  an  enormous  center  of 
infection.  If  the  reader  will  turn  back  to  the  table 
showing  the  extent  of  small-pox  in  the  "  Home  Force  " 
of  the  British  Navy  (p.  274),  he  will  notice  the  very 
remarkable  entry  for  1864,  of  no  fewer  than  199  cases 
of  small-pox  and  9  deaths.     Now  more   than  three- 


292  HANDBOOK  OF   VACCINATION. 

quarters  of  these  cases  (151),  and  two-thirds  of  the 
deaths  (6),  were  from  infection  at  Portsmouth.  Nor 
was  this  all :  from  infection  traced  to  Portsmouth  the 
disease  manifested  itself  on  board  the  Duncan,  when  on 
its  voyage  from  the  North  American  station ;  38  men 
were  temporarily  disabled  by  it,  and  1  died.  In  like 
manner,  in  the  year  following,  of  the  6411  deaths  from 
small-pox  which  occurred  in  England,  1419,  or  more 
than  one-fifth,  were  among  the  664,161  inhabitants  of 
14  unions,  which  not  only  themselves  suffered  the  con- 
sequences of  their  neglect  of  infantile  vaccination,  but 
became  so  many  centers  of  pestilence.*     Surely  the 

t>„  ..!„*•  _  Deatha  from 

,n  1851-  In  1SU5. 

Northampton 41,152 151 

Whitehaven 39,950 126 

Bath 68,336 106 

Dover 31,575 73 

Burton-on-Trent 41,065 72 

Brighton 77,693 70 

Shrewsbury 25,784 59 

Canterbury 1 16,643 55 

Merthyr 93,008 185 

Neath 58,583 153 

Newport  (Mon.) 51,412 104 

Pontypool 30,288 92 

Pontypridd 30,387 91 

Cardiff 58,285 82 

In  many  of  these  places  this  mortality  was  but  part  of  the 
mortality  of  the  town  or  union  from  the  epidemic,  many 
deaths  having  occurred  toward  the  end  of  the  preceding  year, 
as  at  Brighton, .Bath,  Shrewsbury,  and  Burton,  or  still  more 
especially  in  the  six  Welsh  unions,  in  which  there  had  been, 


PROTECTION  AGAINST  SMALLPOX.         293 

continuance  of  a  state  of  things  like  this  is  not  to  be 
regarded  as  a  matter  of  mere  local  concern  :  surely  it 
was  time  for  the  legislature  not  to  leave  it  optional 
any  longer  to  local  authorities  whether  to  enforce  or 
not  the  vaccination  of  the  young  population  ;  but  to  im- 
pose this  enforcement  upon  them  as  a  positive  duty. 

There  still  exists  in  the  minds  of  many  people  a  mis- 
apprehension on  the  subject  of  neglect  of  vaccination. 
If  in  a  number  of  families,  or  say  in  a  whole  district, 
all  the  children  two  years  old  and  upward  are  found 
vaccinated — the  parents,  in  fact,  being  well  disposed 
to  vaccination — and  only  the  children  under  two  years 
of  age  are  unvaccinated,  it  might  be  said  (indeed  it 
has,  under  some  such  circumstances,  been  repeatedly 
said  to  me)  that  there  is  no  neglect  of  vaccination. 
Even  in  official  documents  it  used  to  be  argued  that 
the  number  of  vaccinations  annually  performed  in  the 

in  1864,  244  small-pox  deaths:  most  of  these  places,  besides, 
had  had  similar  visitations  of  fatal  small-pox  but  a  few  years 
before,  which  might  in  themselves  have  been  a  sufficient  warn- 
ing. Three  of  the  places  in  this  list — Merthyr,  Northampton, 
and  Shrewsbury  —  are  among  the  four  unions  which  (from 
their  gross  neglect  of  vaccination)  had  exhibited  the  highest 
mortality  from  small-pox  among  the  children  living  under 
five  years  of  age  in  the  decennial  period  1851-60.  (See  Table 
in  Sixth  Report  of  M.  O.  of  P.  C,  p.  8.)  I  had  reported  of 
Northampton  in  1860  that  it  exhibited  greater  neglect  of  vac- 
cination than  any  other  place  I  had  up  to  that  time  visited : 
and  five  years  afterward  (at  the  time  of  the  epidemic  here 
referred  to),  Dr.  Stevens  stated  it  to  be  the  least  vaccinated 
town  of  the  least  vaccinated  county  he  had  that  year  in- 
spected ;  "  that  it  has  been,  and  still  is,  a  center  in  which 
smalUpox  is  constantly  present,  and  from  which  that  disease 
is  largely  distributed  to  the  neighboring  towns  and  villages." 


294  HANDBOOK  OF   VACCINATION. 

kingdom  was,  irrespective  of  the  age  at  which  the  vac- 
cinations were  done,  the  test  of  the  efficiency  with 
which  vaccination  was  carried  out.  To  the  Epidemi- 
ological Society  belongs  the  merit  of  having  pointed 
out  the  fallacy  and  the  danger  involved  in  this  mode 
of  regarding  the  subject.*  The  period  of  infancy  be- 
ing particularly  obnoxious  to  the  ravages  of  small- 
pox, any  delay  in  the  performance  of  vaccination, 
beyond  the  earliest  period  at  which  it  can  properly 
be  done,  is  neglect.  Previous  to  the  Report  of  the 
Society,  and  the  legislative  action  taken  upon  it, 
more  than  half  the  public  vaccinations  of  the  king- 
dom were  not  performed  till  children  were  above  a 
year  old :  but  if  half  the  children  born  were  left  to 
be  a  year  old  before  being  vaccinated,  there  would  on 
any  given  day  be  in  England  some  300,000  children, 
or  thereabouts,  under  one  year  of  age  alone  (at  a  time 
of  life  when  small-pox  is  so  peculiarly  fatal),,  unpro- 
tected against  the  pestilence.  It  is  by  overlooking  this 
important  consideration,  that  in  countries  on  the  con- 
tinent of  Europe,  conspicuous  for  the  care  with  which 
vaccination  is  carried  out  and  the  good  general  results 
derived  therefrom,  an  epidemic  of  small  pox  is  found 
every  now  and  then  to  carry  off  many  victims.  This 
has  been  the  case  in  Sweden,  where  vaccination  is 
strictly  compulsory ;  but  the  compulsion  not  taking 
effect  till  two  years  of  age,  and  the  vaccination  being 
frequently  deferred  by  parents  till  then,  a  number  of 
unprotected  and  susceptible  subjects  is  kept  up.  The 
most  conspicuous  result  in  England  of  the  Act  of  1853 

*  Keport  of  Small-pox  and  Vaccination  Committee  (op.  cit.), 
p.  19. 


PROTECTION  AGAINST  SMALL-POX.         295 

has  been  the  change  that  has  taken  place  with  regard 
to  the  age  at  which  vaccination  is  now  performed,  and 
to  this  is  due  in  great  measure  the  diminution  in  the 
mortality  from  small-pox. 

But  the  neglect  of  vaccination,  which  on  the  recent 
official  inquiries  was  found  to  obtain  in  a  very  large 
proportion  of  the  districts  into  which  England  is  di- 
vided, was  a  neglect  which  far  exceeded  the  period 
of  infancy.  Frequently  children  who  were  of  age  to 
be  in  attendance  at  infant  schools  were  found  unvac- 
cinated  in  the  proportion  of  15,  20,  and  25  percent, 
of  the  school  attendance :  in  some  districts  the  pro- 
portion had  exceeded  a  third,  and  had  even  mounted 
up  to  a  half.* 

The  small  relative  proportion  of  cases  in  which,  on 
these  inquiries,  it  was  found  that  vaccination,  in  its 
mode  of  performance,  had  been  carried  to  the  extent 
necessary  for  the  full  development  of  its  protective 
powers,  has  already  been  stated  (§  73,  b). 

98.  Summary. — The  evidence  then  is  conclusive 
that  the  vast  majority  of  mankind  may,  by  a  single 
properly  performed  vaccination,  be  rendered  wholly 
unsusceptible  of  any  subsequent  action  of  the  variolous 
poison  ;  and  that  in  the  minority,  whose  susceptibility 
to  that  infection  has  not  been  entirely  exhausted  by 
the  vaccine  process,  the  small-pox  will,  with  rare  ex- 
ceptions, be  so  modified,  that  if  all  the  population  were 
completely  vaccinated,  i.e.  vaccinated  in  the  best  way, 
serious  and  spreading  small-pox  would  be  but  little 

*  Even  in  National  Schools,  attended  by  much  older  chil- 
dren, it  was  not  unusual  to  find  8  or  10  per  cent,  unvaccin- 
ated.  Many  of  these  children  had  already  suffered  the  con- 
sequences of  neglect,  and  were  marked  by  small-pox. 


296  'HANDBOOK  OF   VACCINATION. 

known  among  us,  and  entries  of  fatal  small-pox  would 
be  all  but  banished  from  our  death-registers.  What  is 
to  be  done  for  those  in  whom  vaccination  has  not  been 
properly  performed,  or  has  not  properly  taken  effect — 
in  what  way  a  larger  measure  of  protection  may  be 
extended  to  those  who,  though  properly  vaccinated, 
are  still  in  some  degree  amenable  to  the  small-pox  in- 
fection, are  points  next  to  be  considered. 

It  will  be  well,  however,  first  briefly  to  recapitulate 
the  more  important  conclusions  established  by  the  facts 
stated  in  this  chapter. 

1.  Natural  small-pox,  though  with  rare  exceptions 
it  protects  the  human  constitution  against  any  further 
attack  of  the  same  disease,  does  not  invariably  do  so. 
Persons  have  had  small-pox  twice,  thrice,  and  oftener. 
Absolute  protection  against  an  attack  of  small-pox  does 
not  exist. 

2.  Small-pox  induced  by  successful  inoculation  pro- 
tects generally  like  an  attack  of  the  natural  disease, 
but — to  a  certain  degree  from  the  imperfections  insepa- 
rable from  an  artificial  process,  and  to  a  much  more 
considerable  extent  from  errors  or  carelessness  in  the 
performance  of  the  inoculation  or  from  disturbance  in 
its  course — a  larger  proportion  of  those  who  have  had 
small-pox  by  inoculation  than  of  those  who  have  had 
the  natural  disease,  are  liable  to  a  second  attack  of 
variola. 

3.  Second  small-pox,  whether  after  the  natural  or 
the  inoculated  disease,  is  very  often  modified  in  its 
course,  and  is  much  less  fatal  than  small-pox  in  unpro- 
tected persons.* 

*  Marson  gives  19  per  cent,  as  the  proportion  of  deaths  to 
cases  of  second  small-pox  in  the  Small-pox  Hospital  (Table, 


PROTECTION  AGAINST  SMALL-POX.         29T 

4.  Though  the  practice  of  variolous  inoculation  is 
not  wholly  void  of  risk,  that  risk  is  so  slight  as  com- 
pared with  the  dangers  of  natural  small-pox,  that,  were 
there  no  other  way  of  protecting  the  system  against 
that  disease,  it  is  a  practice  of  which  every  prudent 
person  would  be  glad  to  avail  himself.  But  inocula- 
tion, though  thus  on  the  whole  beneficial  to  the  indi- 
vidual, has  the  effect  of  keeping  alive  and  diffusing  the 
variolous  poison  ;  whence  the  effects  of  it,  as  noted  on 
the  population  generally,  were  not  to  diminish,  but 
considerably  to  increase,  the  small-pox  mortality.  For 
the  last  twenty-seven  years  the  practice  has,  in  Eng- 
land and  Ireland,  been  very  properly  made  illegal. 

5.  Vaccination,  without  endangering  the  life  of  the 
individual  submitted  to  it,  and  without  diffusing  any 
infection,  entirely  and  permanently  exhausts  the  sus- 
ceptibility to  small-pox  in  the  vast  majority  of  those 
in  whom  it  has  been  properly  performed  ;  but  leaves 
an  undetermined  proportion  still  subject  in  a  greater  or 
less  degree  to  the  action  of  the  variolous  poison. 

6.  In  those  whose  susceptibility  has  been  only  par- 
tially destroyed,  the  action  of  the  variolous  infection 
may  be  manifested  at  any  period,  from  a  few  weeks  or 
months  to  any  number  of  years,  after  the  performance 
of  the  vaccination:  but  it  is  most  frequently  not  mani- 
fested till  after  puberty,  and  when  manifested  before 
puberty  is  generally  inconsiderable  in  degree  and  only 
quite  exceptionally  fatal. 

7.  The  degree  of  severity  which  post-vaccinal  small- 

p.  242).  The  returns  to  the  Epidemiological  Society  gave  a 
much  smaller  proportion  of  mortality  than  this — 8-3  per  cent. 
(Seaton,  op.  cit.,  p.  354.) 

26 


298  HANDBOOK  OF   VACCINATION. 

pox  may  manifest  after  puberty  is  chiefly  determined 
by  the  perfection  of  character  and  the  sufficiency  of 
amount  of  the  vaccination  that' has  been  performed. 
Even  when  the  vaccination  has  been  the  most  imper- 
fect, leaving  but  a  single  mark  of  indifferent  character, 
the  disease  is  still  in  most  instances  modified  in  its 
course,  and  is  not  fatal  in  one  third  the  proportion  of 
cases  in  which  natural  small-pox  is  fatal ;  but  when  the 
vaccination  has  been  done  in  the  best  known  manner, 
the  modification  is  so  general  and  so  great  that  the 
proportion  of  deaths  to  attacks  is  scarcely  more  than 
one-seventieth  part  of  that  which  occurs  in  the  natural 
disease. 

8.  It  is  therefore  a  matter  of  vital  importance  with 
regard  to  the  controlling  small-pox  through  the  agency 
of  vaccination  that  the  vaccination  should  be  always 
done  in  the  best  known  manner. 

9.  The  protective  influence  of  vaccination  extends  to 
all  climates  and  all  races ;  and  in  countries  where  the 
practice  is  general,  the  small-pox  mortality  has  declined 
under  its  influence  to  a  fraction  of  that  which  formerly 
prevailed.  In  England,  notwithstanding  a  very  serious 
amount  of  neglect,  and  an  average  performance  of  the 
operation  susceptible  of  very  great  improvement,  it  has 
reduced  the  death-rate  by  small-pox  to  one-fifteenth 
part  of  what  it  was  at  the  close  of  last  century. 

10.  A  strict  enforcement  of  vaccination  in  early  in- 
fancy, and  the  most  scrupulous  care  as  to  the  complete 
and  perfect  performance  of  vaccination,  would  further 
reduce  to  a  small  fraction  of  its  present  amount  the 
still  considerable  small-pox  mortality  of  this  kingdom. 


OF  REVACCINATWN.  299 


CHAPTER    XII. 

OP   REVACCINATION. 

99.  Purposes  for  which  Revaccination  is  necessary. 
— It  was  a  cardinal  rule  with  Jenner,  and  has  ever 
been  the  practice  of  those  who  have  been  careful  to  fol- 
low his  precepts,  whenever  any  irregularity  had  oc- 
curred in  a  vaccination,  to  warn  the  parent  or  other 
person  concerned  that  such  vaccination  could  not  be 
relied  on  as  securing  against  small-pox,  and  that  the 
process  must  either  immediately,  or  at  some  suitable 
time,  be  renewed:  and  it  would  have  saved  many  a  dis- 
appointment, and  added  greatly  to  the  confidence  of 
the  public,  if  Jenner's  practice  of  watching  vaccinations 
throughout  their  course  with  a  view  to  the  application, 
in  all  necessary  cases,  of  this  essential  rule,  had  been 
uniformly  adopted.  Many  of  the  cases  of  post-vaccinal 
small-pox  which  are  met  with  in  practice  are  in  persons 
whose  vaccination  had  been  irregular  or  imperfect. 
When,  also,  after  a  lapse  of  years,  it  became  evident 
that  some  individuals,  whose  vaccination  had  been 
normal  in  its  course,  might  yet  afterward  be  suscepti- 
ble of  small-pox  infection,  and  that  these  cases  occurred 
chiefly  to  persons  who  were  grown  up,  the  idea  of  re- 
newing the  vaccine  process,  once  or  oftener,  in  the  life- 
time of  each  individual,  naturally  suggested  itself. 
When,  further,  the  necessity  of  a  certain  amount  of 
local  infection  in  vaccinating  was  recognized,  revaccina- 


300  HANDBOOK   OF    VACCINATION. 

tion  was  looked  to  for  supplying  this  amount  in  cases 
in  which  in  the  original  vaccination  it  had  been  deficient. 
Hence  the  present  practice  of  revaccination  aims  at 
much  more  than  Jenner  thought  of:  it  aims  not  only 
(1)  at  repairing  whatever  was  irregular  in  the  course 
of  a  primary  vaccination,  but  also  (2)  at  supplying 
what  was  imperfect  in  the  amount  of  infection  in  cases 
in  which  the  course  of  the  disease  was  regular,  and 
further  (3)  at  extinguishing  the  susceptibility  to  small- 
pox which  may  remain,  or  may  rearise,  in  an  inde- 
terminate number  of  persons  whose  primary  vaccina- 
tion may  have  been  complete  as  well  as  regular. 

100.  Carelessness  in  Primary  Vaccination  not  to  he 
excused  on  the  ground  that  Revaccination  will  make 
good  its  defects. — But  before  proceeding  to  consider 
the  rules  under  which  revaccination  should  be  practiced, 
one  important  preliminary  observation  must  be  made. 
No  practitioner  should  ever  allow  himself  to  neglect  or 
overlook  any  means  in  his  power  of  making  a  primary 
vaccination  perfect,  under  the  notion  that  imperfection 
may  easily  be  made  right  by  revaccination.  This 
caution  is  not  offered  without  ample  experience  that  it 
is  called  for;  cases  having  come  to  my  knowledge  not 
unfrequently  in  which  lymph  had  been  used  of  the  effi- 
ciency of  which  the  practitioner  had  himself  doubts,  in 
the  belief  that  it  might  take,  and  that  if  it  did  not  take, 
no  harm  was  done,  as  it  was  easy  to  repeat  the  opera- 
tion. And  what  has  happened  again  and  again  under 
such  circumstances  has  been  this :  the  vaccination  has 
taken,  but  it  has  taken  badly ;  either  at  once,  or  at  some 
no  distant  period,  the  vaccination  has  been  repeated, 
and  perhaps  done  a  third  time,  but  ineffectually  (for  it 
will  constantly  happen  that  spurious  vaccination  will 


OF  REVACCINATION.  301 

prevent  subsequent  vaccination  from  taking  effect  prop- 
erly) ;  then  no  more  is  thought  about  it,  or  the  child  is 
perhaps  declared  "insusceptible;"  it  grows  up,  gets 
small-pox,  and  very  likely  dies.  Or,  probably,  the 
parents  were  directed  to  bring  the  child  again  at  some 
specified  time,  and  failed  to  do  so,  and  the  same  fate 
as  in  the  other  case  befalls  it.  Take  it  at  the  best,  an 
originally  imperfect  or  incomplete  vaccination  is  a  very 
great  misfortune. 

101.  Age,  etc.  at  which  Revaccination  should  be 
performed. — But,  supposing  it  to  have  occurred,  how 
is  the  practitioner  to  act?  Is  he  to  revaccinate  at 
once,  or  is  he  to  wait  till  after  puberty,  when,  as  we 
have  seen,  the  danger  of  insufficient  vaccination  chiefly 
manifests  itself?  He  must  be  guided  in  determining 
partly  by  the  degree  of  imperfection,  and  partly  by  the 
liability  to  exposure  to  small-pox. 

(a)  Circumstances  under  which  it  is  called  for  in 
Childhood.  —  If  a  vaccination  is  found  on  inspection 
imperfect  in  character,  if  it  is  spurious,  irregular,  or 
disturbed  and  spoilt  in  its  course,  the  first  thing  would 
be  to  ascertain  whether  there  might  not  be  something 
in  the  child's  then  state  of  health  which  had  been  over- 
looked, but  which  might  account  for  these  irregularities 
or  imperfections.  If  such  should  turn  out  to  be  the 
case,  this  must  be  corrected  before  any  attempt  is  made 
to  revaccinate  the  child ;  but  if  there  should  be  nothing 
of  this  kind,  the  vaccination  may  be  repeated  at  the 
earliest  opportunity.  Probably  the  revaccination  will 
not  take,  at  all  events  will  not  take  properly;  but  it 
may  take  perfectly.  Anyhow  the  chance  must  be 
given,  and  given  with  the  utmost  care  to  produce 
effect.  When  local  result  follows,  even  though  it  be 
86* 


302  HANDBOOK  OF   VACCINATION. 

only  the  spurious  or  modified  effect  generally  following 
the  revaccination  of  a  properly  vaccinated  person,  the 
practitioner  will  have  done  all  he  can  at  the  time,  and 
need  recommend  no  further  proceedings  till  puberty— 
at  all  events  unless  there  should  arise  some  immediate 
danger  of  small-pox.  But  if  there  be  no  local  evidence 
that  the  lymph  applied  on  the  revaccination  had  been 
absorbed,  the  operation  should  be  repeated  at  intervals 
until  he  is  satisfied  that  the  child  is,  for  the  time  at  all 
events,  insusceptible.  Supposing,  however,  the  defect 
of  the  primary  vaccination  to  have  consisted,  not  in  im- 
perfection of  character  of  the  vesicle  induced,  but  in  an 
insufficient  amount,  or  dose,  if  I  may  so  say,  of  vac- 
cination— that  is,  supposing  one  vesicle  only  to  have 
risen  instead  of  the  four  or  five  the  operator  had  de- 
sired to  produce,  but  that  vesicle  a  good  one — revac- 
cination may,  except  under  circumstances  of  immediate 
danger,  be  left  with  propriety  until  the  child  grows  up. 

We  should  be  guided  by  similar  rules  in  determining 
from  the  cicatrices  left  on  the  arms  of  young  children 
whether  revaccination  is  called  for.  If  these  be  de- 
cidedly imperfect  in  character,  revaccination  should 
be  performed  with  as  little  delay  as  possible :  but  if 
the  cicatrices  be  deficient  in  number  only,  or  if  the 
character,  though  less  strikingly  good  than  it  might  be, 
is  yet  genuine,  the  child  may  be  considered  safe  up  to 
the  age  of  puberty,  but  its  revaccination  at,  or  soon 
after,  that  period  of  life,  should  be  strictly  enjoined. 

But  when  there  is  immediate  exposure,  or  much  risk 
of  exposure,  to  small-pox  infection, — when  children 
are  in  a  house,  or  in  a  crowded  court,  in  which  there, 
is  a  case  of  small-pox, — revaccination  may  with  pro- 
priety be  carried  further :  those   children  who  have 


OF  REVACCINATION.  303 

marks  at  all  imperfect,  or  who  have  not  at  least  two 
decidedly  characteristic  marks,  should,  unless  revac- 
ciuation  have  already  been  tried  upon  them  with  local 
result,  be  revaccinated. 

(b)  It  should  be  performed  on  all  persons  after 
Puberty. — Revaccination  about  or  after  puberty  is  of 
extreme  importance  when  the  primary  vaccination  has 
been  anything  short  of  Marson's  highest  class,  and  is 
necessary  in  proportion  as  it  falls  short  of  it :  but  it 
seems  also  certain  that  a  revaccination  at  or  after 
this  period  of  life,  may  give  additional  security  to 
many  whose  original  vaccination  has  been  complete. 
In  some  of  these,  as  we  have  already  seen,  the  suscep- 
tibility to  variola  is  not  wholly  exhausted,  and  such 
may  contract  the  disease,  though  no  doubt  with  slight 
comparative  danger,  after  growing  up.  But  even  in 
its  most  modified  form,  small-pox  is  a  disease  which 
all  would  desire  to  escape,  and  well  conducted  revac- 
cination appears  to  afford  a  very  sure  and  reliable 
means  of  such  escape.  After  successful  revaccination, 
small-pox,  even  of  the  most  slight  or  modified  kind,  is 
rarely  met  with.  Thus,  Heim  found  that  in  five  years 
there  occurred  among  14,384  revaccinated  soldiers  in 
Wirtemberg,  only  one  instance  of  varioloid,  and  among 
30,000  revaccinated  persons  in  civil  practice,  only  two 
cases  of  varioloid  (one  of  which  was,  probably,  really 
a  case  of  chicken-pox),  though  during  these  years 
small-pox  bad  prevailed  in  344  localities,  producing 
1674  cases  of  modified  or  unmodified  small-pox  among 
the  not  revaccinated,  and  in  part  not  vaccinated,  popu- 
lation of  363,298  persons  in  those  places  in  which  it 
had  prevailed.  In  the  Prussian  army,  since  the  intro- 
duction of  systematic  revaccination  in  1834,  the  cases 


304  HANDBOOK  OF   VACCINATION. 

reported  as  "varioloid,"  and  still  more  those  called 
"  variola,"  have  been  nearly  all  of  them  among  that 
portion  of  recruits  whose  turn  for  revaccination  had 
not  come,  or  whose  revaccinations  had  not  been  suc- 
cessful, or  who  were  incubating  small-pox  when  they 
were  revaccinated  ;  in  the  twenty  years  which  imme- 
diately succeeded  the  adoption  of  this  system  there  oc- 
curred altogether  but  forty  deaths  from  small-pox  in 
this  large  army — or  an  average  of  two  deaths  per  an- 
num— only  four  of  the  entire  forty  being  in  persons 
who  (it  was  said)  had  been  successfully  revaccinated. 
So,  in  the  Bavarian  army,  in  which  there  has  been 
compulsory  revaccination  since  1843,  there  had  not, 
from  that  date  up  to  the  time  of  a  report  made  by  the 
Minister  of  War  in  1855,  been  a  single  case  of  unmodi- 
fied small-pox,  and  only  a  very  few  cases  of  modified 
small-pox  without  any  deaths.  And  other  national 
experiences  might  be  cited  to  the  like  effect.*  Nothing 
can  put  in  a  stronger  light  the  value  of  revaccination 
than  Marson's  statement  of  his  experience  at  the 
Small-pox  Hospital.  He  tells  us,  firstly,  that  during 
the  period  of  his  connection  with  the  hospital,  not  one 
of  the  nurses  or  servants  had  taken  small-pox  during 
her  residence  there,  each  one  of  them  who  had  not  al- 
ready had  small-pox  having  been  carefully  revaccin- 
ated before  being  allowed  to  enter  on  her  duties ; 
and,  secondly,  that  when  the  new  hospital  was  built 
(some  thirteen  or  fourteen  years  ago),  and  a  large 
number  of  workmen  were  there  employed  for  several 
months  after  the  arrival  of  the  patients,  most  of  the 
workmen  consenting  to  be  revaccinated,  not  a  single 

*  See  Sirnon,  Papers  relating,  etc.,  pp.  xxxv.  xxxvi. 


OF  REVACCIXATION.  305 

case  of  small-pox  occurred  among  those  so  consenting, 
while  twocases  of  the  disease  did  occur  among  the  few 
who  were  not  revaccinatcd.*  In  places  where  small- 
pox has  been  epidemic,  the  total,  or  all  but  total,  ex- 
emption of  revaccinated  persons,  when  others  who  had 
been  vaccinated  in  childhood,  but  not  revaccinated 
since,  were  in  some  proportion  attacked,  has  been 
matter  of  quite  familiar  observation  among  medical 
practitioners.  The  reports  of  the  Academie  Imperiale 
de  Medecine  abound  with  such  cases  ;f  and  from  them, 
and  other  sources,  many  instances  might  be  cited  pre- 
cisely parallel  to  Marson's  observations  on  the  work- 
men at  the  Small-pox  Hospital — instances  in  which 
the  revaccinated  members  of  an  infected  family  es- 
caped any  form  of  infection,  while  those  who  had 
declined  revaccination,  had  to  sustain  an  attack  of 
small-pox.  Nor,  wherever  smalJ-pox  has  broken  out 
in  public  institutions,  and  means  have  been  at  once 
taken  to  revaccinate  those  adolescents  or  adults  who 
had  not  before  been  revaccinated,  and  those  children  who 
properly  required  it,  am  I  aware  of  a  single  instance 
in  which  the  disease  has  not  been  summarily  brought 
to  an  end. 

From  these  considerations  we  draw  the  important 
practical  rule,  that  every  person  should  take  care  to  be 

*  Marson  in  Medico-Chir.  Trans.,  vol.  xxxvi.  (op.  cit.). 
He  had  then  been  connected  with  the  hospital  above  seven- 
teen years  :  but  the  statement  with  regard  to  the  nurses  holds 
equally  good  now,  after  a  connection  of  more  than  thirty-two 
years. 

f  Rapport  de  l'Academie  Imp.  de  Med.  sur  les  Vaccinations, 
etc.,  1847,  p.  16;  1848,  p.  21;  1849,  p.  19;  1852,  p.  50;  1853, 
p.  14  seq.;  1854,  p.  14  seq.,  etc.  etc. 


306  HANDBOOK  OF   VACCINATION. 

revaccinated  about,  or  soon  after,  the  period  of  puberty. 
Under  ordinary  circumstances,  about  fifteen  years  of 
age  is  the  best  time  for  it  to  be  done;  and  it  should  not 
be  left  much  beyond  this,  for  the  age  of  most  danger 
from  post-vaccinal  small-pox  is  from  fifteen  to  twenty- 
five.  On  the  other  hand,  where  there  is  any  unusual 
risk  of  small-pox,  as  in  localities  in  which  the  disease 
is  prevailing,  it  would  be  imprudent  to  wait  so  long, 
and  the  re  vaccination  may  be  done  at  any  period  after 
twelve  years  of  age,  or,  in  individual  cases,  even  earlier 
than  this.  In  girls,  especially,  in  whom  the  changes 
connected  with  puberty  manifest  themselves  early,  re- 
vaccination  may  be  performed  correspondingly  early. 
The  degree,  however,  in  which  vaccinated  persons, 
when  they  are  grown  up,  stand  in  need  of  revaccina- 
tion,  is,  I  repeat,  very  different.  Those  who  have  im- 
perfect marks  need  it  much  more  than  those  whose 
marks  are  characteristic;  those  who  have  but  one  or 
two  good  marks  much  more  than  those  with  three  or 
four.  Small,  indeed,  as  the  risk  of  contracting  the 
variolous  infection  in  any  form  is  to  those  who  have 
been  thoroughly  vaccinated,  who  have  four  good  marks 
of  their  vaccination,  and  infinitely  small  as  is  to  them 
the  risk  of  having  it  severely,  it  is  a  risk  not  worth  the 
running ;  and  as  no  individual  can  tell  whether  he  is 
one  of  the  wholly  protected  majority,  or  one  of  the 
but  partially  protected  minority,  it  is  the  part  of  wis- 
dom, even  for  the  best  vaccinated,  to  seek  the  addi- 
tional security  of  a  revaccination. 

102.  Kevaccination  requires  the  same  care  and 
pains  in  its  performance  as  Primary  Vaccination. — 
In  revaccinating — if  revaccination  is  to  be  anything 
more  than  a  deception  and  a  sham — the  same  care  must 


OF  REVACCINATION.  307 

be  used,  and  as  much  pains  taken  to  insure  succeess, 
as  in  performing  a  primary  vaccination.  Revaccina- 
tion  should  be  done,  as  far  as  possible,  from  the  arm, 
and  the  lymph  must  be  always  of  the  very  best.  No 
doubtful  lymph  must  ever  be  used.  "  L'essentiel,"says 
Bousquet,  "  est  de  n'employer  a  la  revaccination  qu'un 
vaccin  dont  on  soit  parfaitement  sur,  sinon  l'epreuve  ne 
meriterait  aucune  confiance  .  .  .  Cependant  nous  avons 
connu  des  medecins  qui  se  servaient  de  vaccin  sec,  con- 
serve sur  verre ;  ils  echouaient  le  plus  souvent,  et  de 
leurmauvais  succes  ils  concluaient  hardimental'inutilite" 
de  la  revaccination.  C'est  aussi  pour  eux  que  nous 
disons  qu'elle  est  sans  valeur  1 'experience  >dont  on  peut 
rejeter  le  mauvis  succes  sur  le  vice  des  procedes  ou  sur 
la  maladresse  de  l'artiste."*  But  much  worse  than  the 
negative  mischief  arising  from  the  use  of  dry  lymph 
has  been  the  positive,  as  well  as  negative,  mischief 
which  I  have  known  result  from  using  the  lymph  of 
revaccinations.  Several  instances  of  this  have  fallen 
under  my  observation.  The  practice  cannot  be  too 
strongly  reprehended.  Even  with  the  best  lymph,  and 
with  every  care,  we  shall  meet  with  failure  in  a  very 
large  proportion  of  cases,  probably  from  a  third  to  a 
half  of  those  operated  upon  ;  and  in  many  or  most  of 
these  an  immediate  repetition  of  the  operation  may  not 
be  attended  with  success.  Such  cases  should  be  noted 
for  a  further  trial  at  some  future  time.  But  persons  in 
whom  the  revaccination  has  so  far  taken  as  to  give 
clear  evidence  that  the  lymph  was  absorbed  (§  47 — for 
it  is  only  in  a  minority  of  the  operations  that  the  same 
degree  of  success  as  attends  a  primary  vaccination  is 

*  Rapport  de  l'Acad.  Imp.  de  Med.  1854,  p.  21. 


308  HANDBOOK  OF   VACCINATION. 

attained)  may  feel  themselves  perfectly  safe — that  is  to 
say,  as  safe  as  any  human  proceeding-  can  make  them — 
against  future  small-pox.  The  experience  of  the  Small- 
pox Hospital  with  regard  to  their  servants  and  nurses 
may  be  appealed  to  confidently  in  proof  of  this.  The 
repetition  of  revaccination  every  five  or  seven  years, 
or  at  whatever  other  intervals  people  may  choose  ar- 
bitrarily to  fix,  or  whenever  they  get  frightened  because 
an  epidemic  of  small-pox  is  about,  is  mere  trifling, — a 
practice  unsupported  by  reason  or  by  observation.  In 
so  far  as  it  may  be  thought  well  in  particular  cases  to 
use  it  to  meet  the  caprices  of  a  timid  patient,  I  have 
nothing  more  to  say  against  it  than  that  I  think  it  be- 
hooves us,  as  members  of  the  medical  profession,  to  be 
the  leaders  rather  than  the  followers  of  the  public  in 
these  matters.  But  the  practice  is  wholly  uncalled  for. 
One  thoroughly  good  primary  vaccination  to  start  with 
(for  that  is,  as  Marson  says,  the  sheet-anchor),  and  one 
careful  revaccination  after  puberty,  so  conducted  as  to 
give  evidence  that  the  lymph  was  absorbed,  are  all 
that  is  necessary  for  complete  protection — protection 
as  complete  as  any  known  proceedings  can  give — 
against  small-pox.  If  the  primary  vaccination  have 
not  been  thorough,  it  must  be  reserved  for  medical 
judgment  to  determine  whether,  and  when,  in  that  par- 
ticular case,  revaccination  before  puberty  might  be  de- 
sirable :  and  in  the  preceding  subsection  I  have  en- 
deavored to  state  what,  as  it  appears  to  me,  should 
determine  that  judgment. 

103.  The  performance  of  Revaccination  should  not 
be  left  to  periods  when  Small-pox  is  epidemic— As 
revaccination  is,  like  primary  vaccination,  a  strictly 
precautionary  measure,  it  is  needless  to  say  that  we 


OF  RE  VACCINATION.  309 

ought  not  to  wait  till  small-pox  is  at  hand  to  have  it 
performed.  The  revaccination  of  persons  as  they  reach 
about  fifteen  years  of  age  should  be  as  systematically 
done  as  is  the  vaccination  of  young  infants.  My  expe- 
rience of  revaccination,  as  it  is  at  present  conducted 
in  England,  has  shown  me  that,  except  by  an  intelli- 
gent few,  it  is  only  practiced  at  times  when  small-pox 
is  epidemic,  and  people  under  the  influence  of  panic. 
It  is  then  generally  done  with  very  little  selection,  and 
more1  according  to  the  fears  of  individuals  than  accord- 
ing to  the  judgment  of  the  practitioner.  It  is  squan- 
dered accordingly  where  it  is  not  wanted  at  all,  or  is 
of  very  little  moment,  and  is  frequently  omitted  in  the 
very  cases  in  which  it  is  most  urgently  necessary.  Be- 
sides which,  a  pressure  for  lymph  is  in  this  way  often 
put  upon  the  practitioner  which  it  is  very  difficult  for 
him  to  meet.  If  careful  arrangements  be  necessary  to 
carry  on  a  series  of  primary  vaccinations,  most  of  which 
will  be  reproductive  of  lymph  fit  for  use,  how  much 
more  to  carry  on  a  large  series  of  revaccinations,  which 
exhaust,  but  do  nothing  to  replenish  the  operator's 
lymph-supply.  Under  these  circumstances  there  is  a 
temptation — a  temptation,  I  regret  to  say,  not  always 
resisted — to  use  any  sort  of  lymph,  and  even  to  em- 
ploy the  lymph  of  revaccinations.  If  the  public  can 
only  be  made  to  understand  how  much  worse  an  arti- 
cle they  run  a  risk  of  getting  by  putting  off  their  pre- 
cautionary measures  to  a  period  of  panic,  they  will  be 
more  careful,  I  apprehend,  than  heretofore  to  get  their 
revaccination  done  beforehand. 

Under  the  regulations  which  are  now  in  force  for 
public  vaccination,  the  vaccinators  are  authorized  to 
revaccinate  at  the  public  expense  all  applicants  above 

27 


310  HANDBOOK  OF   VACCINATION. 

fifteen  years  of  age  who  have  not  before  (so  far  as  can 
be  ascertained)  been  successfully  revaccinated,  or,  if 
there  be  immediate  danger  of  small-pox,  all  who  have 
attained  the  age  of  twelve  years. 

104.  Local  results  of  Revaccination :  no  indication 
is  derivable  therefrom  as  to  the  person's  liability  to 
contract  Small-pox. —  The  immediate  results  of  the 
performance  of  revaccination  may  be  either  the  com- 
plete umbilicated  vaccine  vesicle  (§  34),  or  the  modi- 
fied vesicle  or  papule  (§  47),  or  entire  failure.  The 
following  table,  exhibiting  the  results  of  revaccination 
on  each  1000  individuals  revaccinated  in  the  Wirtem- 
berg  army  in  1831-5,  and  in  our  own  army  in  1861, 
appears  to  me  to  represent  a  larger  ratio  of  complete 
results  (perfect  vaccine  vesicles)  than  we  ordinarily 
meet  with  in  civil  practice,*  but  there  is  no  statistical 
record  of  re  vaccinations  in  civil  practice  made  on  so 
large  a  scale  as  would  justify  me  in  presenting  it.  It 
shows,  at  all  events  approximately,  what  may  be 
looked  for  in  the  revaccination  of  adults  generally. 


*  The  proportion  of  complete  successes  in  revaccination 
reported  in  the  annual  returns  of  the  British  army,  varies 
greatly  in  different  years,  and  in  the  same  year  in  different 
corps.  It  has  sometimes  been  such  as  to  lead  to  the  belief 
that  proper  judgment  was  not  exercised  in  discriminating  the 
perfect  and  the  modified  vesicle,  and  toward  the  end  of  1865 
a  circular  was  addressed  to  the  medical  officers  on  this  subject 
by  the  Director-General. 


OF  REVACCINATION. 


311 


L.    X 

*  2 

1 

•  2 

a 

Cur 

if 

£"3 

lid 

o  o-3 

III 

o*5 

Persons  in  whom  the 

.  Degree  of 

■2 1 

la  § 

3£S 

Oca 

Ro  vaccinations  were 
performed. 

Success  of 
Revaccination. 

■S'SJ 

*  |  a 

J  feu 

1°  § 

HO 

"1 

o-—  £ 

So* 

aj3  = 

*H 

a 

H 

s 

Wirtembprg  Army, 
1831-5 

(13,861  cases). 

319-5 

310-4 

280-7 

337-3 

2481 
432-3 

1000 

280-5 
409-2 

259-0 
460-4 

1911 
471-6 

1000 

1000 

1000 

Soldiers  in  Brit.  Army, 
not  recruits,  in  1861 

451-4 

484-6 

236-8 

3260 

159-6 

157-4 

505-3 

277-5 

(2053  ciiaes). 

None - 

389-0 

3580 

257-9 

396-5 

1000 

1000 

1000 

1000 

Recruits  in  Brit.  Army, 
in  1861 

345-5 

407-3 

461-3 

527-3 

266-8 

240-8 

301-3 

202-6 

(4395  cases). 

387-7 

loot) 

351-9 

"iooo 

237-4 

270-1 
1000 

1000 

One  important  practical  conclusion  we  clearly  derive 
from  this  table,  and  from  the  large  experience  which  is 
now  accumulated  on  the  subject  of  revaccination. 
The  local  results  obtained  by  the  revaccination  of  any 
individual  give  us  absolutely  no  information  whatever 
as  to  the  constitutional  condition  in  which  the  re-vac- 
cinated person  was  with  regard  to  liability  to  contract 
small-pox.  It  has  frequently  been  argued,  and  is  in- 
deed often  to  be  heard  said  now,  that  if  a  revaccination 
cannot  be  made  to  take,  or  if  it  take  only  in  a  modified 
way,  it  is  evidence  that  the  constitution  would  not  at 
the  time  take  small-pox ;  whereas,  if  a  complete  local 
result  follow,  it  may  be  assumed  that  the  protection  of 
the  primary  vaccination  had  worn  out,  and  that  the 
person  was  in  danger,  or  at  all  events  in  more  danger 


312  HANDBOOK  OF   VACCINATION.      • 

than  in  the  former  case,  of  taking  the  variolous  infec- 
tion. Now,  if  this  were  so,  the  Wirtemberg  results 
would  prove  that  319  out  of  every  thousand  persons 
who  had  had  small-pox,  310  out  of  every  thousand  who 
had  been  well  vaccinated,  but  only  281  out  of  every 
thousand  who  had  been  ill  vaccinated,  were  in  present 
danger  of  taking  small-pox ;  and  of  the  soldiers  (not 
recruits)  in  our  own  army,  451,  485,  and  237  would  rep- 
resent the  ratio  in  the  three  classes  respectively,  which 
is  clearly  a  reductio  ad  absurdum.  M.  Yleminkx,  find- 
ing the  results  of  his  revaccinations  of  the  prisoners 
in  Belgium  more  successful  in  those  who  had  marks  of 
small-pox  than  in  those  who  had  good  marks  of  vac- 
cination, in  the  proportion  of  30  per  cent,  of  the  former 
to  19  per  cent,  of  the  latter,  argued  that  it  was  more 
important  to  vaccinate  persons  who  had  had  small-pox 
than  to  revaccinate  persons  who  had  good  marks  of 
vaccination:  with  perfect  logical  consistency,  if  only 
the  premises  were  sound  that  the  "  taking"  of  vaccine 
in  a  protected  person  shows  anything  whatever  with 
regard  to  the  liability  to  receive  variola.  Jenner 
himself  distinctly  pointed  out  that  this  was  not  the 
case.  "Although,"  he  says  in  his  first  Tract,  "the 
cow-pox  shields  the  constitution  from  the  small-pox, 
and  the  small-pox  proves  a  protection  against  its  own 
future  poison,  yet  it  appears  that  the  human  body  is 
again  and  again  susceptible  of  the  infectious  matter  of 
the  cow-pox  :"*  and  he  gives  instances  in  which  the 
cow-pox  was  thus  taken  twice  or  thrice  by  persons  who 
could  not  be  variolated  either  by  inoculation  or  by 
exposure.     Further,  in  one  of  his  subsequent  essays, 

*  Obs.  on  the  Variolae  Vaccinae,  p.  21. 


OF  REVACCINATION.  313 

speaking-  of  the  vaccination  of  those  who  had  already 
had  small-pox,  he  observes  that  "  although  the  suscep- 
tibility of  the  virus  of  the  cow-pox  is  for  the  most  part 
lost  in  those  who  have  had  the  small-pox  yet  in  some 
constitutions  it  is  only  partially  destroyed,  and  in 
others  it  does  not  appear  to  be  in  the  least  diminished. 
By  far  the  greater  number  on  whom  trials  were  made 
resisted  it  entirely ;  yet  I  found  some  on  whose  arms 
the  pustule  from  inoculation  (vaccination)  was  formed 
completely,  but  without  producing  the  common  efflores- 
cent blush  around  it,  or  any  constitutional  illness,  while 
others  have  had  the  disease  in  the  most  perfect  man- 
ner."* Exactly  in  the  same  way,  as  he  pointed  out, 
the  perfect  variolous  pustule,  a  pustule  capable  of  com- 
municating variola  to  others,  may  be  raised  in  the  skin 
of  a  person  who  has  had  variola  without  in  the  least 
degree  giving  him  a  second  time  the  disease  variola.f 
The  utility  and  necessity  of  revaccination  do  not 
stand  on  any  speculative  reasoning  from  the  local  phe- 
nomena it  develops,  but  upon  broad  grounds  of  observ- 
ation and  experience. 

*  Continuation  of  Facts,  etc. 

f  "  Upon  the  skin  of  every  human  being  that  possesses  a 
more  than  ordinary  share  of  irritability,  the  insertion  of  the 
variolous  virus  ( whether  the  person  has  previously  had  the  cow- 
pox  or  small-pox)  will  produce  either  a  pustule  or  a  vesicle 
capable  of  communicating  the  small-pox,  and  frequently  at- 
tended with  extensive  inflammation."  (Letter  to  Mr.  Bod- 
dington  in  Baron's  Life,  vol.  i.  p.  445.) 

27* 


314  HANDBOOK  OF   VACCINATION. 


CHAPTER    XIII. 

OF   STAMPING-OUT   LOCAL   OUTBREAKS   OF  SMALL-POX. 

105.  Universal  Vaccination  would  render  the  dan- 
gers of  Small-pox  quite  inconsiderable. — If  all  the 
children  throughout  the  kingdom  were  properly  vac- 
cinated in  early  infancy,  as  the  law  requires,  with  due 
care  to  watch  the  process  in  each  instance,  and  to 
remedy  in  any  spurious,  doubtful,  or  imperfect  case 
what  had  been  amiss — still  more  surely  if,  as  each  child 
attained  puberty,  the  vaccination  were  repeated — we 
should  soon,  I  apprehend,  have  little  or  no  small-pox 
current  among  us.  At  all  events,  the  risks  of  importa- 
tion of  the  disease  into  any  locality  would  be  as  no- 
thing to  what  they  now  are,  and  there  would  be  little 
or  no  danger  of  its  ever  spreading  :  for  when  an  impor- 
tation did  take  place,  our  anxieties  being  limited  to 
that  small  and  manageable  part  of  the  population,  on 
whom,  on  account  of  their  tender  age  or  indifferent 
health,  vaccination  had  not  yet  been  done,  the  easy 
task  of  vaccinating  immediately  such  of  those  as  ran 
any  risk  of  exposure  to  the  infection  would  soon  be 
accomplished. 

106.  Dangers  to  which  now  the  Careful  are  sub- 
jected by  the  Careless. — But,  as  things  now  are,  with 
whatever  care  the  local  authority  or  the  local  officers  of 
particular  districts  or  places  may  keep  their  native 
populations   protected,  they   cannot   avoid   the   risks 


OF  STAMPING-OUT  SMALL-POX.  3J5 

arising  both  from  the  immigration  into  their  districts  of 
unprotected  families,  and  from  the  frequent  importation 
of  small-pox  from  other  and  neglected  places.  Thirty 
times  in  one  year,  as  we  have  seen,  was  small-pox  im- 
ported into  the  district  of  Mold,  chiefly  from  neglected 
Liverpool ;  and  though  the  precautions  taken  and  the 
vigilance  exercised  in  that  district  were  quite  sufficient 
to  prevent  the  disease  from  spreading  from  any  one  of 
these  centers  of  infection, — for  nowhere,  where  due 
vigilance  is  used,  need  small-pox  spread, — still  the 
strain  at  present  imposed  upon  those  who  are  careful 
by  those  who  "are  careless  is  very  great. 

107.  Steps  that  should  be  taken  immediately  on 
Importation  of  Small-pox  to  prevent  its  spreading. — 
When  a  case  of  small-pox  is  imported  anywhere,  the 
first  thing  must  be  to  isolate  it  as  far  as  possible.  When- 
ever an  airy  room  can  be  given  up  to  it,  there  will  be 
no  necessity  whatever  to  move  the  case  to  a  hospital, 
even  where  the  opportunity  for  such  removal  exists; 
but  where,  as  among  most  of  the  laboring  classes,  etc., 
there  are  no  such  means  of  isolation,  but  the  case  would 
have  to  remain  in  a  room  to  which  many  must  have 
access,  and  in  which  perchance  some  part  of  the  family, 
or  perhaps  the  whole  family,  might  be  sleeping,  if  not 
altogether  living,  removal  to  a  hospital,  or  place  of 
proper  isolation,  is  of  the  utmost  consequence,  and 
wherever  it  is  practicable  should  never  be  omitted.  It  is 
greatly  to  be  lamented  that  there  are  not  provided,  as 
there  ought  to  be,  within  the  bounds  of  every  sanitary 
jurisdiction  in  the  kingdom,  and  especially  in  every 
town,  places  for  the  reception  of  cases  of  small-pox, 
and  of  the  other  infectious  fevers,  with  a  view  to  their 
isolation  and  treatment ;  and  it  is  to  be  hoped  that  the 


316  HANDBOOK  OF   VACCINATION. 

powers  which  the  Sanitary  Act  has  conferred  on  local 
authorities  for  this  object  will  not  be  suffered  to  remain 
dormant  * 

The  next  thing-  is  to  take  care  that  those  who  have 
to  deal  with  the  case,  or  are  likely  in  any  way  to  come 
in  contact  with  it,  are  thoroughly  protected.  The  arms 
of  all  in  the  house  must  at  once  be  examined;  the  un- 
vaccinated  must  be  vaccinated  without  any  delay ;  the 
inmates  above  twelve  years  of  age  who  have  not  already 
been  successfully  vaccinated  since  attaining  that  age, 
should  be  revaccinated,  and  if  all  cannot  be  done  at  the 
same  time  those  should  be  done  first  whose  marks  are 
the  most  imperfect,  or  the  fewest;  and  (though  this 
can  well  afford  to  be  left  till  the  other  things  have  been 
looked  to)  the  vaccinated  children  who  have  not  at  least 
two  marks  of  good  quality  should  also  be  revaccinated. 
When  the  house  is  situated  in  a  crowded  court,  it  is 
well  to  extend  these  precautionary  measures  at  once  to 
the  other  houses  in  the  court. 

And  the  last  thing — never  to  be  omitted — is  care- 
fully to  disinfect  every  article  of  clothes,  bedding,  etc. 
which  have  been  used  for  the  sick  person,  and  after  the 

*  This  is  really  a  matter  of  the  most  urgent  necessity.  It 
is  often  now  a  very  difficult  thing  to  know  how  to  dispose  of 
a  case  of  small-pox  when  it  occurs  ;  and  in  the  anxiety  of  one 
parish  to  get  rid  of  it,  and  the  determination  of  another  not 
to  receive  it,  I  have  known  the  most  cruel  things  done.  But 
hesides  the  means  of  isolation,  so  immediately  called  for,  an 
eventual  want  is  the  power  of  compelling  it  (not  necessarily, 
of  course,  in  a  hospital,  but  in  some  way  that  should  be  ap- 
proved by  a  competent  authority) ;  and  there  should  certainly 
be  some  severe  penalty  on  concealment  of  the  existence  of 
small-pox. 


OF  STAMPTNG-OUT  SMALL-POX.  31? 

disease  is  over  to  disinfect  the  room  and  the  furniture 
of  the  room  in  which  the  case  has  been. 

These  measures,  thoroughly  and  promptly  carried 
out,  are  pretty  certain  to  limit  the  attack  to  the  im- 
ported case  or  cases,  when  the  surrounding  population 
generally  is  in  a  good  state  of  protection,  and  I  have 
again  and  again  known  them  successful  when  the  sur- 
rounding population  generally  was  but  very  imper- 
fectly protected.  A  community  imperfectly  protected 
is  subject,  however,  to  two  great  risks  of  the  infection 
spreading,  which  all  the  injunctions  of  the  practitioner 
with  regard  to  isolation  may  not  suffice  to  guard 
against:  (1)  whether  from  mistaken  kindness  or  from 
love  of  gossip,  a  case  of  small-pox  really  appears  fre- 
quently to  be  an  attraction  to  the  neighbors,  and  the 
infected  house  a  favorite  place  of  rendezvous ;  and  if 
it  be  a  mild  case  in  a  child,  it  is  pretty  certain  that 
some  of  the  neighbors'  children  will  be  sent  in  to  play 
with  the  patient;  and  (2)  from  the  great  modification 
small-pox  generally  undergoes  in  the  vaccinated,  there 
is  often  so  little  illness  that  it  is  very  difficult  to 
keep  the  patient  even  in  doors,  and  much  less  in  a  par- 
ticular room  or  part  of  a  house  ;  and  as  the  disease 
has,  by  its  modification,  lost  nothing  of  its  power  of 
infecting  others,  it  is  constantly  becoming  diffused  in 
this  way,  in  spite  of  all  warnings,  and  in  spite  of  the 
prohibitions  of  the  law.*     Hence  whenever  there  is 

*  Under  the  thirty-eighth  clause  of  the  Sanitary  Act,  1866, 
persons  exposing  themselves,  or  their  children,  or  others  af- 
fected with  small-pox,  in  the  streets,  or  in  any  public  places, 
or  public  conveyances,  may  be  proceeded  against  summarily; 
before  that  enactment,  they  could  only  be  punished  by  the 
tedious  and  expensive  process  of  indictment.    See  on  this,  and 


318  HANDBOOK  OF   VACCINATION. 

importation  of  small-pox  into  a  badly  protected  district, 
it  is  a  very  urgent  matter,  as  soon  as  the  immediate 
surroundings  of  the  imported  case  or  cases  have  been 
looked  to,  to  work  up,  if  I  may  so  say,  the  general 
vaccination  of  the  district. 

108.  Steps  necessary  to  arrest  it  when  it  has  begun 
to  spread.  Necessity  for  Prompt  Action. — When  to 
the  earliest  cases  of  small-pox  no  such  barriers  as  I 
have  described  have  been  opposed,  or  when  these  bar- 
riers have  been  overleapt,  and  the  disease  has  begun 
to  spread,  this  spread  is  at  first  generally  slow,  and 
many  weeks  elapse  before  there  is  anything  like  epi- 
demic diffusion.  And  it  depends  entirely  on  whether 
advantage  is  taken  of  this  interval  or  not,  whether 
there  ensue,  even  in  places  in  which  vaccination  had 
been  much  neglected,  an  inconsiderable  or  a  formidable 
mortality.  If  we  take,  for  example,  the  outbreaks  of 
small-pox  which  occurred  in  Cardiff  and  in  Sheffield, 
in  1857,  both  atttended  with  enormous  mortality  in 
unvaccinated  young  children,  and  the  progress  of  which 
was  as  follows — 

on  the  powers  of  local  authorities  with  regard  to  disinfection, 
"The  Sanitary  Act,  with  Introduction,  etc.,  hy  J.  B.  Hutchins: 
Knight  &  Co." 


OF  STAMPING-OUT  SMALL-POX. 


319 


1857. 


January.... 
February., 

March 

April 

May 

June 

July 

August.... 
September 
October.... 
November 
December 

Total. 


Deaths  from  Small-pox. 


Cardiff  (town).  Sheffield 


1 

1 

5 

8 

42 

35 

19 

14 

14 

13 

7 

2 


161 


3 

3 

10 

14 

16 

132 


178* 


— we  see  at  once  what  opportunity  there  had  been  in 
the  earlier  weeks  for  repairing  the  gross  neglect  of  vac- 
cination that  had  existed  in  these  places,  and  for  thus 
arresting  the  further  spread  of  the  disease.  And  what- 
ever town,  or  whatever  epidemic  period,  might  be  se- 
lected, the  same  thing  would  be  shown :  Slow  progress 
of  the  epidemic  at  first,  affording  yet  a  period  for  re- 
pairing neglect,  and  subsequent  progress  dependent 
entirely  on  the  activity  or  inactivity  with  which  the 
outbreak  had  been  met. 

In  1858,  when  there  were  111  deaths  from  small-pox 


*  And  these  were  but  the  prelude  to  a  still  more  formidable 
amount  of  mortality  next  year,  when  the  deaths  from  this 
cause  were  290.  There  has  certainly  existed  heretofore  a  very 
scandalous  neglect  of  vaccination  in  Sheffield ;  but  active 
measures,  I  am  informed,  are  being  taken  under  the  powers 
of  the  new  law  to  remedy  this  lamentable  state  of  things. 


320  HANDBOOK  OF   VACCINATION. 

in  the  union,  and  chiefly  in  the  town,  of  Carmarthen, 
there  had,  as  in  the  foregoing  instances,  been  plenty  of 
warning  of  the  approach  of  the  disease  from  adjacent 
rural  districts ;  and  even  after  it  had  reached  the  town 
there  had  been  plenty  of  time  to  prevent  the  catas- 
trophe which  occurred,  for  it  was  not  till  after  a  four 
months'  sojourn  that  extensive  spread  occurred :  some 
forty  or  fifty  cases  and  eight  deaths  represented  the 
extent  of  the  mischief  done  during  the  first  sixteen 
weeks.  In  the  town  and  district  of  Carnarvon,  where 
in  1859  there  were  sixty  deaths  from  small-pox,  and  in 
the  City  of  York,  where  in  1862  there  were  above  a 
hundred  deaths  from  this  cause,  there  had  been  the 
same  warning  of  approach,  the  same  gradual  progress 
of  the  disease  at  first,  the  same  supineness  and  indif- 
ference in  dealing  with  it.  But  in  the  official  reports* 
in  which  these  and  other  similar  cases  are  recorded, 
instances  will  be  found,  on  the  other  hand,  in  which 
under  the  like  circumstances  of  antecedent  neglect,  the 
activity  of  the  local  authorities,  or  of  the  local  officers, 
either  arrested  the  outbreak  altogether,  or  limited  its 
spread,  and  rendered  the  mortality  comparatively 
trifling.  One  illustration  here  must  suffice,  not  se- 
lected by  any  means  because  it  was  the  most  complete 
in  its  results,  but  rather  because  the  local  difficulties 
that  had  to  be  met  were  considerable.  When  small- 
pox broke  out  in  Gravesend  in  1860,  there  were  great 
arrears  of  vaccination.  The  first  step  taken  was  the 
issuing  by  the  local  authority,  on  the  representation  of 
the  public  vaccinators,  of  cautionary  notices;  as  soon 

*  Annual  Reports  of  the  Medical.  Officer  of  the  Privy  Coun- 
cil, iii.-vii.  inclusive. 


OF  STAMPING-OUT  SMALL-POX.  321 

as  the  disease  began  to  spread,  the  managers  of  all  the 
public  schools  insisted  on  the  immediate  vaccination  of 
any  unvaccinated  children  in  attendance  ;  and  the  In- 
spector of  Police  made  personal  inquiry,  founded  on 
the  birth-registers  and  on  his  local  knowledge,  respect- 
ing unvaccinated  children.  When  these  were  found, 
they  were  not  lost  sight  of  till  they  were  vaccinated. 
The  population  being  thus  put  in  a  comparatively  well- 
protected  condition,  the  consequence  was  that,  though 
the  epidemic  lasted  altogether  more  than  a  year,  there 
were  but  four  deaths  from  small-pox  in  children  ille- 
gally unvaccinated :  there  were  eleven  other  deaths 
from  this  cause,  but  five  of  these  were  in  adults,  and 
two  in  young  babies  born  at  the  time  their  mothers 
were  suffering  from  the  disease.* 

Directly,  then,  that  in  any  district  small-pox  has 
begun  to  spread  beyond  its  points  of  importation,  the 
utmost  vigilance  and  promptitude  of  action  of  the  local 
authority  are  called  for.  Whatever  arrears  of  primary 
vaccination  may  exist  must  be  immediately  dealt  with ; 
and  all  the  means  with  which  the  law  has  armed  local 
authorities  for  finding  out  the  unvaccinated  population, 
and   obtaining   their  protection,   at  once   exercised  f 

*  The  remaining  four  were  in  children  not  subject  to  the 
provisions  of  the  compulsory  law. 

f  Systematic  inquiries  respecting  young  children  (under  two 
years  of  age)  whose  successful  vaccination  has  not  been  regis- 
tered, is  one  important  means.  Hereafter,  this  is  directed  to 
take  place  regularly  every  six  months,  irrespective  of  whether 
small-pox  be  present  or  not.  Another  important  rrieans  is  the 
examining  the  children  attending  various  charitable  schools, 
especially  infant  schools.  If  all  the  managers  of  such  schools 
would  make  it  an  absolute  rule  not  to  admit  any  child  without 
28 


322  HANDBOOK  OF   VACCINATION. 

And  those  adults  or  adolescents  who  have  not  already, 
since  growing  up,  been  successfully  revaccinated, 
should  be  urged  to  avail  themselves  at  once  of  the  re- 
vaccination  which  is  everywhere  freely  provided  for 
them  (page  308).  But  the  essence  of  the  complete 
success  of  these  measures  lies  in  their  being  taken 
without  delay.  So  long  as  local  authorities  will  make 
light  of  "  a  few"  cases  of  small-pox,  and  hesitate  to 
take  efficient  steps  "  for  fear  of  creating  alarm,"  so  long 
will  epidemic  outbreaks  flourish. 

109.  Steps  necessary  for  its  Arrest  when  it  has  be- 
come extensively  diffused. — But  suppose  these  import- 
ant steps  have  been  thus  improperly  delayed,  and  that 
the  place  has  become  thoroughly  infected  before  any 
active  measures  of  suppression  have  been  adopted. 
Even  under  these  adverse  circumstances,  it  is  quite 
possible  to  arrest  within  a  very  short  time  the  fatality 
of  the  disease,  and,  in  a  little  while  further,  to  extin- 
guish it  altogether.  But  the  measures  which  almost 
certainly  would  have  sufficed  before,  will  not  now  be 
enough,  and  others  must  be  taken  adequate  to  the 
emergency.  The  infected  localities  must  be  mapped  out 
and  systematically  visited  from  house  to  house,  from 
room  to  room,  and  from  child  to  child.  Though  it  is 
not  in  the  least  necessary  that  this  visitation  should  be 
made  by  a  public  vaccinator,  or  by  a  medical  practi- 
tioner, and  though  often,  indeed,  it  would  be  a  mere 
waste  of  force  to  employ  medical  agency  for  the  pur- 

a  medical  certificate  of  its  successful  vaccination,  or  without 
having  its  arms  examined  by  the  public  vaccinator  of  the 
district,  it  would  be  a  very  useful  check  upon  neglect.  But  it 
is  not  enough  to  make  a  rule :  they  must  see  that  it  is  carried 
out. 


OF  STAMPING-OUT  SMALI^-POX.  323 

pose,  yet,  when  other  circumstances  admit  of  such 
employment,  there  are  obvious  advantages  derivable 
from  the  knowledge  which  medical  men  generally  have 
of  the  population,  and  from  their  influence  over  them. 
Much,  no  doubt,  will  depend  on  the  kind  of  population 
which  has  to  be  dealt  with.  But  the  person  employed, 
if  not  a  medical  man,  must  at  all  events  know  the  proper 
characters  of  the  vaccine  cicatrix,  in  order  that  he  may 
be  able  to  examine  for  himself  the  arms  of  the  children 
in  the  houses  that  he  has  to  visit.  His  first  and  most 
important  duty  in  this  visitation  will  be  to  see  that  the 
cases  found  illegally  unvaccinated  are  taken,  according 
to  previous  arrangement,  to  a  vaccinator  ;  and  he  should 
at  the  same  time  endeavor  to  procure  the  immediate 
vaccination  of  unvaccinated  children,  who  are  below 
the  age  at  which  non-vaccination  becomes  illegal, 
pointing  out  to  parents  the  extreme  danger  of  delay. 
If  he  meet  with  vaccinated  children  whose  vaccine 
marks  are  doubtful  or  imperfect,  he  should  induce  the 
parents  to  send  them  for  revaccination.  Further,  he 
must  not  neglect  to  urge  upon  adults,  who  have  not 
already  been  successfully  revaccinated,  the  necessity 
for  being  revaccinated  forthwith.  By  a  judicious  exer- 
cise of  firmness  and  kindness  all  this  may  be  readily 
done.  The  families  visited,  however,  must  not  be  lost 
sight  of:  having  received  their  directions,  they  must 
be  visited  again,  to  see  that  these  have  been  complied 
with ;  and  they  must  be  kept  in  view  until  their  full 
protection  is  obtained.  If  these  measures  be  thoroughly 
carried  out,  and  if,  as  their  indispensable  complement, 
measures  of  thorough  disinfection  be  also  steadily  pur- 
sued, the  eradication  of  the  small-pox  from  the  locality 
will  certainly  follow.     But  that  they  may  "fee  completely 


324  HANDBOOK  OF   VACCINATION. 

effectual,  they  must  be  systematically  undertaken  and 
intelligently  supervised.  The  services  of  a  good  medi- 
cal officer  of  health  are  here  invaluable.  Assuredly  no 
circumstances  could  have  been  more  difficult  or  un- 
promising than  those  under  which,  in  18fi0,  the  small- 
pox was  routed  out  of  the  crowded  population  of  South 
St.  Giles's,  London,  at  the  height  of  the  very  severe 
epidemic  then  prevalent  in  the  metropolis.  The  dis- 
ease had  extended  to  that  district  in  September,  1859, 
and  at  first  made  therein  its  usual  gradual  progress : 
but,  also,  as  usual,  after  a  three  months'  sojourn,  or 
thereabouts,  the  mortality  from  it  leapt  up  all  at  once 
from  thirteen  deaths,  spread  over  a  quarter  of  a  year, 
to  nine  deaths,  in  two  weeks.  Local  inquiries  also 
showing  the  disease  to  be  then  rapidly  spreading,  im- 
mediate authoritative  interference  was  determined  on. 
The  representations  which,  in  conjunction  with  the 
medical  officer  of  health  of  the  district,  I  made  to  the 
Board  of  Guardians,  led  to  its  directing  a  most  com- 
plete visitation,  for  the  purpose  of  which  it  offered  to 
put  on  any  amount  of  force  that  might  be  required. 
The  public  vaccinator  of  the  district,  however,  under- 
took himself  to  get  the  work  done ;  and  so  completely 
and  with  such  energy  was  it  set  about  that,  in  a  few 
days,  all  the  infected  localities  had  been  thoroughly 
visited  by  himself  or  his  deputy ;  169  children,  totally 
unprotected  against  small-pox,  many  of  them  in  tJw 
very  houses,  and  some  in  the  very  rooms,  with  small- 
pox cases,  having  been  discovered  and  vaccinated, 
and  a  number  of  imperfectly  vaccinated  children 
having  been  revaccinated.  The  impression  thus  made 
on  the  mortality  of  the  small-pox  was  such  that,  ex- 
cepting some  cases  which  were  incubating  the  disease, 


OF  STAMPING-OUT  SMALL-POX.  325 

when  they  were  visited,  there  were  but  three  more 
deaths  from  it  in  South  St.  Giles's  up  to  the  termination 
of  the  epidemic  in  London,  eight  months  afterward, 
only  one  of  these  deaths  being  in  parochial  practice, 
and  that  one  being  an  accidental  case  four  months  after 
the  date  of  the  visitation.  Now  that  this  immediate 
arrest  of  the  mortality  was  really  due  to  the  measures 
employed,  and  did  not  arise  from  the  epidemic  having 
happened  to  come  to  a  natural  termination  in  St.  Giles's 
just  at  the  period  these  measures  were  taken,  was  not 
only  to  be  inferred  from  the  large  number  of  unpro- 
tected persons  discovered  to  be  living  within  the  im- 
mediate influence  of  the  infection,  who,  had  they  not 
been  thereupon  vaccinated,  would,  we  may  be  quite 
sure,  have  had  to  sustain  an  attack,  but  was  actually 
proved  by  the  fact,  that  for  the  first  three  or  four  weeks 
following  their  adoption,  the  cases  of  small-pox  in  the 
vaccinated  continued  to  be  as  numerous  as  before,* 
after  which  lapse  of  time  this  class  of  cases  also  grad- 
ually diminished,  till  the  disease  died  out  altogether. 
The  cases  of  post-vaccinal  small-pox  which  were  ad- 
mitted during  the  month  preceding  the  visitation  were 
twenty  eight,  and  those  admitted  during  the  month 

*  In  correspondence,  in  short,  with  the  progress  of  epidemic 
force,  which,  according  to  the  natural  history  of  the  disease, 
would  have  manifested  its  continuance  among  the  unvac- 
cinated  also  at  this  period  but  for  the  interference  which  had 
taken  place;  it  should  also  be  explained,  in  reference  to  these 
post-vaccinal  cases,  that  the  primary  vaccination  of  the  locali- 
ties visited  was  made  complete;  the  revaccination,  especially 
of  adults,  from  their  being  away  from  home  at  the  times  of 
the  visits,  or  in  some  instances  from  their  being  unwilling  to 
be  revaccinated,  was  not  so  complete  as  was  desirable. 
28* 


326 


HANDBOOK  OF   VACCINATION. 


immediately  succeeding  it  were  twenty-nine.  The  fol- 
lowing abstract  of  the  small-pox  register  of  the  district 
medical  officer,  for  the  half  year  during  which  the  epi- 
demic lasted  in  South  St.  Giles's,  from  October  1,  1859, 
to  March  31,  1860, — arranged  in  two  periods,  the  one 
before  and  the  other  after  the  house-to-house  visitation 
had  time  to  take  effect, — shows  what  that  visitation  ac- 
comp':shed: 


Cases  of  Small-pox  admitted. 

IN  VACCINATED 

IN   UNVACCINATED 

PLRSONS. 

PERSONS. 

Date. 

J 

a 

E 

£ 

3 

5 

a 
5 

3 

3 

1 

s 

£ 

<a 

<n 

B 

a 

6 

3 

49 
41 

51 
41 

A 

13 

a 

s 

H 

p 

Oct.  1  to  Jan.  21 

2 

1 

29 
4 

12 

2 

41 

6* 

14 

Jan.  21  to  Mar.  31.. 

In  reference,  however,  to  the  measures  of  house-to- 
house  visitation  which  are  necessary  for  thoroughly 
eradicating  small-pox  when  it  has  been  allowed  to  get 
epidemically  diffused,  it  is  very  important  to  remember 
that  house-to-house  visitation  is  not  house-to-house 
vaccination.  In  the  visitation  in  South  St.  Giles's, 
though  it  was  made  by  medical  men,  they  did  not 
dream,  except  under  particular  circumstances,  of  stop- 
ping in  each  room  to  do  the  vaccinations  required,  but 
had  the  cases  brought  to  an  appointed  place  by  a  pre- 
organized  arrangement,  so  that  the  vaccinations  were 
done  direct  from  the  arms  of  children.     Under  no  cir- 


*  Of  which  three  occurred  in  a  part  of  the  district  distant 
from  that  which  had  been  visited  from  house  to  house. 


OF  STAMPING-OUT  SMALL-POX.  327 

cumstances  is  it  more  important  that  the  operation 
should  be  done  in  a  way  almost  sure  not  to  fail  than 
when  it  is  done  under  immediate  or  proximate  danger 
of  small-pox. 

110.  Responsibility  of  Local  Authorities  for  pre- 
venting the  Spread  of  Fatal  Small-pox. — Whatever, 
then,  be  the  circumstances  under  which  we  have  to 
encounter  small-pox — whatever  its  stage  of  diffusion — 
we  have  in  vaccination  (including,  of  course,  revac- 
cination  wherever  this  is  necessary)  the  means  of  as- 
suredly controlling  and  subduing  it,  and  in  vaccination, 
along  with  disinfection,  the  means  of  eradicating  it. 
But  these  means  will  invariably  be  found  to  be  easy  or 
difficult  of  application,  to  be  of  very  trifling  cost  or 
a  source  of  heavier  expenditure,  according  as  vaccina- 
tion has  been  previously  cared  for  or  neglected  in  the 
population  to  whom  the  infection  has  come,  and  ac- 
cording to  the  promptitude  with  which  the  disease  has 
been  met  on  its  arrival:  it  is  in  keeping  a  population 
vaccinated  pari  passu  with  the  births  that  the  real 
economy  of  life,  and  health,  and  money  lies.  Under 
the  powers  which  the  present  vaccination  law  confers 
on  local  authorities,  the  spread  of  fatal  small-pox,  let  it 
occur  when  it  may,  must  be  taken  as  in  itself  a  sufficient 
indication  of  the  apathy,  indifference,  or  incompetence 
of  the  local  authority  within  whose  jurisdiction  it  takes 
place."* 

*  No  doubt  the  law  has  hitherto  been  very  imperfect  and 
unsatisfactory,  hut  not  so  imperfect  as  to  leave  any  excuse 
for  the  extreme  neglect  which  has  frequently  been  allowed 
to  prevail.  I  have  lately  been  inspecting  the  Eastern  Dis- 
tricts of  London,  in  which  small-pox  may  be  almost  said 
to  be  endemic,  and  in  which,  last  year,  it  made  great  rav- 


328  HANDBOOK  OF   VACCINATION. 


CHAPTER    XIY. 

OF  THE  OBJECTIONS  TO  VACCINATION,  AND  THE  ALLEGED 
DANGERS  OF  THE  PRACTICE. 

111.  Allegation  that  it  has  produced.  New  Diseases. 
— I  should  deem  it  a  waste  of  the  reader's  time  to  en- 
ter on  any  particular  consideration  of  some  of  the  ob- 
jections that  have  been  advanced  against  vaccination. 
That  it  has  produced  new,  strange,  and  unheard  of 
diseases — that  it  has  caused  degeneration,  mental  and 
physical,  of  the  human  species,  diminishing  men's 
stature,  incapacitating  them  for  the  fatigues  of  mili- 
tary service,  or  even  for  the  exercise  of  dancing,  and 
driving  them  for  consolation  to  tobacco — are  assertions 
that  have  been  very  seriously  and  very  vehemently 
made,  but  against  which  it  is  surely  not  necessary  se- 
riously to  argue.*  The  nonsense  about  degeneration 
has  not,  so  far  as  I  am  aware,  found  any  echo  in  this 

ages.  For  any  special  steps  that  had  been  taken  to  arrest 
it  by  the  local  authorities,  it  could  not  be  supposed  that 
there  had  even  existed  authorities  having  any  responsibility 
whatever  in  a  matter  so  seriously  affecting  the  lives  and  health 
of  more  than  half  a  million  of  our  population,  and  possessing 
powers  for  the  enforcement  of  vaccination  which,  if  duly  exer- 
cised, might  assuredly  have  prevented  a  very  large  proportion 
of  the  terrible  suffering  and  mortality  from  small-pox  that 
had  there  prevailed. 

*  Verde  de  Lisle,  De  la  Degenerescence  Physique  et  Morale 
de  l'Espece  Humaine  determine  par  le  Vaccin.     Paris,  1855. 


OBJECTIONS  TO    VACCINATION.  329 

country ;  and  here  certainly,  since  the  days  of  Row- 
ley, and  Squirrel,  and  Birch,  the  diseases  "produced 
by  vaccination"  have  occupied,  "in  medical  teaching 
and  medical  conversation,  about  the  same  space  as 
diseases  produced  by  witchcraft  and  the  evil  eye."* 

112.  Allegation  that  it  has  led  to  Increase  in  the 
Mortality  of  other  Diseases. — Another  objection  that 
has  been  urged,  equally  destitute  of  medical  support, 
is  that  though  vaccination  may  save  from  small-pox, 
there  has  been  no  real  gain  of  life  after  all,  but  a  mere 
"  displacement  of  mortality,"  the  persons  who  should 
have  figured  in  the  death-register  as  dead  of  small-pox 
appearing  at  some  time  or  other,  but  without  living  to 
grow  old,  in  some  other  column,  as  having  died  from 
some  other  disease.  Of  course,  in  a  certain  sense  and 
to  a  certain  degree,  this  statement  is  quite  true.  Vac- 
cination does  not  profess  to  make  mankind  immortal — 
it  saves  from  small-pox  and  its  sequelae,  and  from 
nothing  else  ;  and  everybody  whom  it  saves  therefrom 
lives  to  die  of  some  other  cause  at  some  future  period. 
One  might  as  well  argue  on  such  grounds  against 
saving  a  man  from  drowning.  To  make  the  objection 
of  any  value  it  would  need  to  be  shown  that  vaccina- 
tion, either  by  some  positive  action  of  its  own,  or  by 
depriving  the  constitution  of  some  advantages  conse- 
quent on  having  small-pox,  leaves  it  more  prone  than 

*  Simon,  Preface  to  Papers  relating  to  the  History  and 
Practice,  etc.  [op.  tit.),  p.  xliii.  To  the  interesting  and  ad- 
mirable chapter  "  On  the  alleged  Drawbacks  from  the  Ad- 
vantages of  Vaccination,"  in  this  Preface,  I  would  refer  the 
reader  for  an  exhaustive  discussion  of  the  subject ;  it  is  well 
worthy  of  the  most  careful  study,  and  I  desire  to  express  my 
own  great  indebtedness  to  it. 


330  HANDBOOK  OF   VACCINATION. 

it  would  otherwise  be  to  take  on  other  diseases,  and 
more  prone  to  such  a  degree  as  to  counterpoise  the 
saving  of  life  and  health  from  small-pox.  Fever  and 
scrofulous  diseases  are  the  diseases  especially  pointed 
out  as  having  taken  the  place  of  small-pox. 

In  support  of  this  notion,  some  statistics,*  imperfect 
in  themselves  and  utterly  misunderstood,  have  been 
advanced  to  show  that,  so  far  is  vaccination  from  hav- 
ing saved  life,  the  general  death-rate  of  populations 
has  increased  since  its  introduction,  that  this  increase  is 
very  notable  at  particular  ages,  and  that  there  has  been 
especial  rise  in  the  death-rates  from  fever  and  scrofulous 
diseases.  Now,  supposing  all  this  had  been  true,  there 
would  yet  have  been  wanting  a  great  deal  more  to 
show  that  post  had  not  merely  been  mistaken  for  prop- 
ter, and  that  these  results  had  in  any  way  depended  on 
the  practice  of  vaccination;  but  it  so  happens  that,  as 
soon  as  the  statements  were  scrutinized  (and  they  were 
immediately  subjected  to  competent  scrutiny,  both  here 
and  abroad),  each  one  of  them  was  found  to  be  the  very 
reverse  of  the  truth.  Thus,  on  comparison  of  the 
present  general  death-rate  with  the  death-rate  of  the 


*  "Collected  with  more  zeal  than  judgment  by  a  former  ar- 
tillery officer,  M.  Carnot."  (Simon,  op.  cit.,  p.  xlvii.)  Car- 
not's  statistics  related  only  to  France,  and  their  fallacies  were 
at  once  exposed  to  the  Academie  des  Sciences  by  Baron  Ch. 
Dupin.  The  reader  who  is  interested  in  this  part  of  the  sub- 
ject, and  who  has  leisure,  will  find  it  treated  ably  and  with 
much  detail  in  a  little  work  by  Dr.  Bertillon,  "  Conclusions 
Statistiques  contre  les  Detracteurs  de  la  Vaccine."  The  reader 
who  has  not  leisure  may  be  very  grateful  to  Simon  for  the 
pains  he  has  taken  to  examine  and  expose,  in  his  own  com- 
pact and  exhaustive  way,  Carnot's  crudities.  He  has  left,  in 
fact,  nothing  more  to  be  learnt  or  said  on  the  matter. 


OBJECTIONS   TO    VACCINATION.  33 1 

middle  of  last  century,  in  any  population  for  which  the 
materials  for  the  comparison  exist,  it  appears  that(a//er 
deducting  the  small-pox  gain)  the  present  rate  is  greatly 
below  that  which  obtained  before  the  date  of  vaccina- 
tion. In  London,  for  example,  the  annual  death-rate 
from  all  causes,  at  the  middle  of  the  last  century,  was 
355  per  10,000  of  population,  and  from  all  causes,  ex- 
cept small-pox,  325 ;  but  in  the  middle  of  the  present 
century  it  was,  including  small-pox,  but  249.  In  Swe- 
den, in  the  period  from  1755  to  1115,  the  general  death- 
rate  was  289  per  10,000  of  population;  from  1841  to 
1850  it  was  but  205.  And  similar  results  are  obtained 
from  the  statistics  of  other  countries.  Again,  analysis 
of  the  death-rates  at  particular  ages,  wherever  the  data 
for  such  analysis  exist,  show  that  this  gain  pertains  to 
all  periods  of  life.  Between  the  ages  of  twenty  and 
forty  years — the  very  time  of  life  when,  it  was  said,  the 
particular  liability  of  those  whom  vaccination  had  saved 
from  small-pox  to  be  carried  off  by  other  diseases  mani- 
fested itself — the  gain  is  very  obvious.  The  mortality 
of  early  life,  and  at  all  ages  short  of  old  age,  has 
steadily  diminished,  and  the  number  of  persons  who 
attain  a  good  old  age  has  as  regularly  increased. 
Lastly,  so  far  as  fe*vers  and  scrofulous  diseases — the 
forms  of  disease  specially  alleged  to  have  taken  the 
place  of  small-pox — from  having  increased  in  frequency 
and  fatality,  that  (as  has  been  clearly  shown  by  Dr. 
Greenhow,  in  a  very  able  and  elaborate  investigation 
of  the  death-rates  of  London,  at  different  ages  and 
from  different  diseases)  there  has  been  a  most  remarka- 
ble diminution.  The  present  death-rate  of  "fever"  (if 
we  include  with  the  deaths  now  registered  under  that 
title  all  those  deaths  of  the  present  day  which  might 


332  HANDBOOK  OF   VACCINATION. 

have  been  included  in  days  gone  by  under  the  term,  as 
scarlet  fever,  and  inflammation  of  the  brain,  and  inflam- 
mation of  the  lungs)  amounts  only  to  385  per  100,000 
of  population,  whereas  a  century  ago  its  death-rate  was 
close  on  539.*  This  diminution  in  the  mortality  from 
fever  has  been  also  fully  established  by  the  researches 
of  that  eminent  statistician  Dr.  Farr,  who  tells  us  that 
this  cause  of  death  has  progressively  subsided  since 
1771,  and  further  that  the  combined  mortality  of  small- 
pox, measles,  and  scarlatina  now  is  "only  half  as  great 
as  the  mortality  formerly  occasioned  by  small-pox 
alone,  "f  The  smaller  mortality  occurring  nowadays 
from  scrofula  and  consumption  has  been  likewise  satis- 
factorily shown  by  both  these  able  inquirers,  working 
from  separate  data.  And  to  the  gain  of  life  in  diseases 
of  this  class  there  cannot,  I  apprehend,  be  any  doubt 
that  vaccination  has  largely  contributed.  It  is  one  of 
the  terrors  of  natural  small-pox  that,  by  its  depressing 
influences  on  the  constitution,  it  frequently  develops, 
in  those  disposed,  the  seeds  of  tubercular  and  other 
scrofulous  diseases.  This  is  repeatedly  noticed  by 
writers  on  scrofula.  Guersant  and  Blache,  in  their 
experience  at  the  Hopital  des  Enfants  Malades  at  Paris, 
were  struck  with  the  effect  which  they  noticed  small-pox 
to  have  in  developing  scrofula  and  pulmonary  phthisis.  J 
"  Having  often,"  says  Dr.  Alison,  "  seen  scrofulous,  espe- 
cially tubercular,  diseases,  originating  during  the  feeble 

*  Simon,  Preface,  etc.  [op.  cit.),  p.  lv.  Dr.  Greenhow's  ex- 
cellent paper,  which  is  well  worthy  of  study,  will  he  found  in 
extenso  in  these  Papers  at  p.  26. 

f  McCulloch's  Descriptive  and  Statistical  Account  of  the 
British  Empire,  4th  edit.  vol.  ii. 

X  Diet,  de  Med.,  art.  "  Variole." 


OBJECTIONS  TO    VACCINATION.  333 

state  of  convalescence  from  bad  small-pox,  and  being 
aware  that  small-pox,  before  vaccination  was  introduced, 
was  always  stated  to  be  a  mutilating,  when  not  a  fatal 
disease,  I  have  no  doubt  that  whatever  prevents  small- 
pox in  a  population  will  save  many  of  that  population 
from  scrofulous  and  tubercular  disease,  otherwise  to  be 
fatal  to  them."*  This  indirect  prevention  of  scrofu- 
lous affections  was,  indeed,  among  Jenner's  hopes 
when  he  announced  the  discovery  of  vaccination.  In 
various  passages  of  his  writings  he  refers  to  the  noto- 
rious frequency  with  which  such  affections  were  excited 
by  small-pox ;  and  he  appeals  to  general  consent  as  to 
inoculated  small-pox  often  occasioning  them.  "  In  con- 
stitutions predisposed  to  scrofula,  how  frequently  we 
see  the  inoculated  small-pox  rouse  into  activity  that 
distressful  malady.  .  .  .  Every  practitioner  in  medi- 
cine who  has  extensively  inoculated  with  the  small- 
pox, or  who  has  attended  many  of  those  who  have  had 
the  distemper  in  the  natural  way,  must  acknowledge 
that  he  has  frequently  seen  scrofulous  affections,  in 
some  form  or  other,  sometimes  rather  quickly,  showing 
themselves  after  the  recovery  of  the  patients,  "f 

The  hypothesis  that  vaccination,  by  rendering  per- 
sons less  liable  to  small-pox,  renders  them  eventually 
more  liable  to  other  diseases,  is  in  fact  contrary  to  the 
whole  current  of  medical  experience.  This  was  clearly 
brought  out  when,  in  1856,  the  Medical  Officer  of  the 
then  Board  of  Health  addressed  to  the  same  members 
of  the  medical  profession  whom  he  consulted  as  to  their 
opinion  on  the  protective  power  of  vaccination,  the 

*  Papers  relating,  etc.   (op.  cit.),  p.  33. 
•J- As  quoted  by  Simon,  Preface,  etc.  (op.  cit.),  p.  lx. 
29 


334  HANDBOOK  OF   VACCINATION. 

further  question,  "Have  you  any  reason  to  believe,  or 
to  suspect,  that  vaccinated  persons,  in  being  rendered 
less  susceptible  of  small-pox,  become  more  susceptible 
of  any  other  infective  disease,  or  of  phthisis ;  or  that 
their  health  is  in  any  other  way  disadvantageously 
affected  ?"  Of  542  respondents,  there  was  not  a  single 
one  who  gave  the  slightest  support  to  the  hypothesis. 
113.  Allegation  that  Cutaneous  and  Glandular  Dis- 
eases may  be  Invaccinated. — Inasmuch  as  cutaneous 
diseases  and  glandular  swellings  are  frequently  noticed 
in  children  subsequent  to  their  vaccination,  parents  are 
often  found  to  allege  that  these  diseases  have  been 
introduced  by  the  vaccination.  But  this  again,  though 
a  popular,  has  never  been  a  professional  belief.  Dis- 
eases of  these  classes  are  met  with  constantly  in  in- 
fancy and  childhood,  as  well  in  the  unvaccinated  as  the 
vaccinated,  from  the  influence  of  various  exciting  causes 
acting  on  constitutional  predisposition.  No  facts  exist 
to  prove,  or  even  to  render  probable,  their  greater  fre- 
quency among  the  vaccinated  than  among  the  unvac- 
cinated of  the  same  ages  respectively:  observation, 
indeed,  tends  to  show  that  there  is  no  such  greater  fre- 
quency.*   When  eczematous  and  other  eruptions  mani- 

*  "As  regards  the  relation  of  vaccination  to  the  infantile 
skin  diseases  of  chronic  character,"  says  Mr.  Hunt,  "  I  can 
confidently  say,  after  examining  and  recording  the  history  of 
upwards  of  a  thousand  cases  of  skin  disease  in  children  (oc- 
curring at  the  Western  Dispensary  for  Diseases  of  the  Skin), 
that  I  find  no  evidence  whatever  that  vaccination  disposes  the 
constitution  to  cutaneous  diseases;  these  appearing,  in  fact,  to 
attack  indiscriminately  the  vaccinated  and  the  unvaccinated. 
Of  course,  since  the  Compulsory  Vaccination  Act  has  heen  in 
operation,  we  have  had  more  cases  of  skin  disease  after  vaccin- 
ation than  we  formerly  had,  simply  because  children  are  now 


OBJECTIONS  TO    VACCINATION.  335 

fest  themselves,  as  they  may  do,  shortly  after  vaccina- 
tion has  been  performed,  this  is  in  fact  usually,  if  not 
always,  mere  coincidence;  and  the  eruption  on  inquiry 
is  found  to  be  really  due  to  the  irritation  of  teething, 
or  probably  to  some  error  in  diet,  or  to  some  general 
constitutional  tendency.  It  may  be,  however,  that  in 
some  cases  vaccination,  by  the  febrile  action  it  sets  up, 
may  act  as  an  exciting  cause,  just  as  a  common  cold 
would  do,  and  thus  be  the  means  of  sooner  evolving 
some  eruptive  disorder  that  was  lurking  in  the  system. 
But  such  cases  are  certainly  exceptional ;  and,  assuredly, 
no  professional  authorities  believe  in  the  transference 
of  glandular  or  cutaneous  diseases  from  one  child  to 
another  by  vaccination.  Parental  complaints  of  such 
communication  arise,  as  M arson  very  justly  states,  from 
the  unwillingness  of  parents  "to  believe  that  there  is 
anything  wrong  in  their  offspring :  and,  when  other  dis- 
eases follow,  vaccination  gets  blamed  for  what  is  really 
and  truly  due  to  other  causes."*  In  corroboration  of  this 
statement,  and  as  illustrating  the  want  of  foundation  of 
such  complaints,  and  the  prejudices  under  which  they 
are  preferred,  I  may  remark  that  having  myself  care- 
vaccinated  at  or  before  three  months  instead  of  at  six,  eight, 
ten,  or  twelve  months  of  age.  Therefore,  a  cutaneous  disease 
which  breaks  out  after  the  third  month,  necessarily  occurs 
after  vaccination.  Formerly,  it  might  at  that  age  have  oc- 
curred be/ore  vaccination.  The  date  of  vaccination  has  made 
the  disease  a  sequence,  not  a  consequence,  of  vaccination. 
Mothers  frequently  entertain  the  belief  that  any  disease  of  the 
skin  occurring  after  vaccination  is  caused  by  it ;  but  I  do  not 
remember  a  single  instance  in  which  any  reasonable  evidence 
of  such  connection  could  be  produced."  (Papers  relating,  etc., 
op.  cit.,  p.  71.) 
*  Papers  relating,  etc.  (op.  cit.),  p.  25. 


336  HANDBOOK  OF  VACCINATION. 

fully  investigated  many  of  them  I  have  never  yet  in  a 
single  instance  found  that  the  child  from  whom  the 
lymph  was  taken  was  suffering  from  the  disease  it  was 
said  to  have  imparted. 

Those  who  have  had  most  to  do  with  the  perform- 
ance of  vaccination,  on  the  one  hand,  and  those  who 
have  been  most  concerned  in  the  treatment  of  infantile 
disease,  on  the  other,  concur  in  the  belief  of  the  non- 
communicability  of  disease  by  vaccination.  Marson 
stated  some  years  ago  that  in  the  performance  of  up- 
wards of  40,000  vaccinations  he  had  "  never  seen  other 
diseases  communicated  with  the  vaccine  disease,  nor 
did  he  believe  in  the  popular  reports  that  they  are  so 
communicated."*  The  experience  of  the  late  Mr.  Leese, 
whose  vaccinations  had  been  scarcely,  if  any,  less  nu- 
merous, was  the  same.f  Sir  W.  Jenner  has  put  on 
record  that  at  University  College  Hospital  and  at  the 
Hospital  for  Sick  Children  he  had,  in  six  years,  more 
than  13,000  sick  adults  and  children  under  observation, 
and  that  in  no  case  had  he  reason  to  believe,  or  even 
to  suspect,  that  any  constitutional  taint  had  been  con- 
veyed from  one  person  to  another  by  vaccination. | 
Dr.  West's  experience,  on  26,000  infants  and  children 
under  his  care  in  seventeen  years,  was  to  the  like  effect; 
and  in  stating  that  he  had  seen  nothing  in  that  time  to 
make  him  believe  that  vaccination  excites  cutaneous 
eruptions  in  any  but  very  exceptional  cases,  he  referred 
such  exceptional  cases  to  a  disposition  in  the  children 

*  Papers  relating,  etc.  His  vaccinations  now  amount  to 
about  60,000,  and  his  experience  remains  the  same. 

f  Seaton  on  Protective  and  Modifying  Powers  of  Vaccina- 
tion {op.  cit),  p.  365. 

%  Papers  relating  to,  etc.,  p.  75. 


OBJECTIONS   TO    VACCINATION.  337 

themselves,  brought  out  by  the  vaccination  as  it  might 
have  been  by  teething.*  And  Professor  Paget,  speak- 
ing from  his  large  experience  among  children  in  the  out- 
patients' room  at  St.  Bartholomew's,  and  enumerating 
some  of  the  causes  which  develop  cutaneous  diseases 
in  young  children,  says,  "Now,  vaccination  may  do, 
though  I  believe  it  very  rarely  does,  what  these  several 
accidents  may  do ;  namely,  by  disturbing  for  a  time  the 
general  health,  it  may  give  opportunity  for  the  exter- 
nal manifestation  and  complete  evolution  of  some  con- 
stitutional affection,  which,  but  for  it,  might  have  re- 
mained rather  longer  latent."  "This  is," he  adds,  "the 
worst  thing  that  can  with  any  show  of  reason  be 
charged  against  vaccination  ;  even  this  can  very  sel- 
dom be  charged  with  truth,  "f 

114.  Allegation  that  Syphilis  may  be  Invaccinated. 
This  is  not  supported  (a)  by  general  Professional 
Experience. — Syphilis  differs  from  any  of  the  other 
diseases  which,  it  has  been  alleged,  may  be  propagated 
by  vaccination,  in  being  an  inoculable  disease;  a  dis- 
ease which,  in  fact,  except  in  the  forms  in  which  it 
manifests  itself  hereditarily,  is  always  the  result  of 
some  inoculation.  But  the  inoculation  which  produces 
it  is  the  inoculation  of  its  own  infection :  and  as  small- 
pox produces  small-pox;  vaccinia,  vaccinia;  and  glan- 
ders, glanders ;  so  does  syphilis  produce  syphilis.  The 
causes  of  all  these  and  of  other  inoculable  infections 
are  specifically  so  distinct  that  it  has  ever  been  held  by 
medical  authorities  in  the  highest  degree  improbable 
that  the  unmixed  inoculable  products  of  any  one   of 

*  Papers  relating,  etc.,  p.  146.  f  Ibid.,  p.  139. 

29* 


338  HANDBOOK  OF   VACCINATION. 

\ 

them  should  convey  any  other  infection  along  with  it; 
and  when,  after  the  introduction  of  small-pox  inocula- 
tion during  the  last  century,  the  objection  was  raised 
that  that  process  might  be  the  means  of  conveying 
syphilis,  enlightened  medical  opinion  rejected  such  a 
supposition  as  not  sustainable.  The  distinguished  Dr. 
Mead  represents  the  conclusions  of  medical  observers 
of  that  period  when,  referring  to  individuals  who  "  in- 
fected with  an  incurable  itch  of  writing,  and  taking 
great  pleasure  in  contradicting  others  to  whom  they 
bear  envy,  .  .  .  still  go  on  to  terrify  us  by  saying  that 
there  is  danger  lest,  together  with  the  small-pox,  some 
other  infection  inherent  in  the  blood  and  humors  of 
the  sick  person  should  be  transmitted  into  the  sound 
body  ;  .  .  .  and  such,  perhaps,  are  scrofulous  swellings 
and  the  venereal  disease,"  he  says,  "yet  I  can  hardly 
believe  that  it  ever  happens  that  the  seed  of  one  dis- 
temper should  bring  along  with  it  mixed  the  procrea- 
tive  matter  of  another  quite  different  from  it.  .  .  .  It 
is  in  my  opinion  more  material  into  what  kind  of  body 
the  venom  be  infused  than  out  of  what  it  be  taken." 
And  Moseley,  in  one  of  his  diatribes  against  vaccina- 
tion, says  in  reference,  not  to  it,  but  to  small-pox  inocu- 
lation: "Suppose  a  subject  in  the  small-pox  to  have 
inveterate  scurvy,  scrofula,  itch,  syphilitic  infection,  or 
consumption,  certainly  no  person  Ought  to  take  matter 
from  such  a  person  for  inoculation.  But  it  might  be 
done  with  as  much  safety  as  if  none  of  these  disorders 
were  present.  Peculiar  circumstances,  which  I  had 
no  share  in  creating,  have  rendered  me  acquainted  with 
some  of  these  facts,  and  accident  the  others."*    What- 

*  See  Simon,  Preface,  etc.  (op.  cit.),  p.  lxv.  and  note. 


OBJECTIONS  TO    VACCINATION.  339 

ever  this  objection  might  be  worth  as  against  small- 
pox inoculation,  it  would  of  course  be  worth  as  against 
vaccination;  but  in  reference  to  this  latter  process  its 
value  has  been  tested  on  an  infinitely  larger  scale,  for 
where  small-pox  inoculations  amounted  to  thousands, 
vaccinations  have  mounted  to  millions,  and  it  may  be 
safely  affirmed  that — prior,  at  all  events,  to  recent  oc- 
currences which  will  be  presently  referred  to,  and 
which  have  caused  the  question  of  the  communicability 
of  syphilis  by  vaccination  to  be  reopened — there  was 
the  utmost  accordance  of  medical  opinion  in  rejecting 
the  possibility  of  such  communication.  This  will  be 
at  once  obvious  to  any  reader  who  will  take  the  trouble 
to  consult  the  replies  given  by  between  five  and  six 
hundred  medical  practitioners,  comprising  nearly  every 
distinguished  medical  authority  in  Great  Britain,  and 
many  or  most  of  those  in  France  and  Germany,  to  the 
question  put  to  them  in  1856  by  the  Medical  Officer  of 
the  then  Board  of  Health :  "  Have  you  any  reason  to 
believe  or  suspect  that  lymph  from  a  true  Jennerian 
vesicle  has  ever  been  a  vehicle  of  syphilitic,  scrofulous, 
or  other  constitutional  infection  to  the  vaccinated  per- 
son?" 'The  distinguished  and  experienced  authorities 
whose  opinions  I  quoted  in  the  previous  section,  as  to 
the  non-coinmunicability  of  disease  generally  by  vac- 
cination, not  only  included  syphilis  with  other  diseases, 
but  specially  included  it ;  Dr.  West  stating  that  there 
had  never  come  under  his  notice  "  any  instance  in 
which  there  seemed  the  slightest  pretext  for  supposing 
that  syphilis  had  been  communicated  to  infants  through 
the  medium  of  the  vaccine  lymph  ;"  and  Professor 
Paget,  that  he  does  not  remember  "  to  have  heard  in- 
fautile  syphilis  ascribed  to  vaccination,  frequent  as  the 


340  HANDBOOK  OF   VACCINATION. 

instances  of  it  [infantile  syphilis]  are  among  the  out- 
patients." Neither  Marson  nor  Leese,  in  their  immense 
vaccinating  experience,  ever  met  with  anything  to 
countenance  the  belief  that  vaccine  lymph  had,  on  any 
occasion,  been  the  vehicle  of  conveying  syphilitic  in- 
fection. And  Mr.  Tomkins,  the  Inspector  of  Vaccina- 
tions of  the  National  Vaccine  Establishment,  who  has 
himself  vaccinated  nearly  50,000  children,  and  whose 
experience  of  the  whole  operations  of  the  Establish- 
ment embraces  thirty  years  of  its  history,  informs  me 
that  no  instance  has  ever  come  to  his  knowledge  of 
syphilis  having  been  communicated  by  vaccination.  If 
we  pass  from  the  evidence  derivable  from  great  expe- 
rience in  vaccination  on  the  one  hand,  to  the  evidence 
supplied  by  practitioners  most  conversant  with  syphilis 
on  the  other,  we  find  that  neither  Acton,  nor  Lee,  nor 
Langston  Parker,  daily  as  they  have  had  to  do  with 
syphilis  all  their  lives,  have  ever  seen  a  case  of  that 
disease  traceable  to  vaccination.  And  though  the  great 
leaders  of  our  profession,  as  Chomel,  or  Rostan,  or 
Bright,  or  Latham,  or  Watson,  or  Brodie,  or  Joseph 
Henry  Green,  may  have  had  little  or  no  experience  in 
the  mere  practice  of  vaccination,  and  some  of  them 
probably  little  to  do  specially  with  syphilis,  their  vast 
and  intimate  knowledge  of  the  nature  of  diseased  pro- 
cesses and  the  laws  by  which  such  processes  are  pro- 
pagated in  the  human  subject  gives  immense  weight  to 
the  opinion  they  unreservedly  express,  that  the  specific 
infection  of  the  one  disease  cannot  convey  with  it  the 
other.  "  The  suggestion  of  its  being  possible,"  says 
Latham,  in  his  own  forcible  way,  "amazes  me."  "I 
apprehend  that  persons  entertaining  such  opinion," 
says  Joseph  Henry  Green  "can  be  only  those  who  are 


OBJECTIONS  TO    VACCINATION.  341 

ignorant  of  the  circumstances  under  which  diseases 
are  ordinarily  propagated."* 

No  doubt,  so  far  as  regards  the  argument  derivable 
from  professional  experience  in  this  matter,  it  may  be 
said  that  it  is  worth  much  less  than  at  first  sight  it 
might  appear  to  be,  because  vaccinators  are  careful  to 
avoid  syphilitic  children  as  sources  for  continuing  their 
lymph ;  and  though  our  vaccinations  count  now  by 
millions,  the  vaccinations  from  syphilitic  sources  must, 
after  all,  have  been  very  few.  Unquestionably  this  is 
so  :  comparatively,  they  must  certainly  have  been  very 
few.  We  may  justly  think  with  pride  of  the  care  which 
for  the  most  part  the  profession  has  taken,  in  this 
country  at  all  events,  to  guard  the  purity  of  vaccina- 
tion.- Whatever  carelessness  or  looseness  in  the  per- 
formance of  vaccination  there  may  often  have  been,  it 
is  not  in  indifference  as  to  the  subjects  from  whom 
lymph  was  token  that,  in  professional  hands,  this  care- 
lessness has  in  England  manifested  itself.  Still,  even 
among  us,  there  has  been  so  much  miscellaneous  and 
non-professional  vaccination,  and  with  many  practi- 
tioners the  strength  of  the  conviction  that  it  was  im- 
possible to  communicate  by  vaccine  lymph  any  other 
than  its  own  contagion  has  been  so  great,  that  I  cannot 
persuade  ni}rself  but  that,  in  the  course  of  seventy 
years,  vaccination  from  children  having  some  hered- 
itary taint  of  syphilis  must  have  occurred  often  enough 
to  constitute  an  experiment  of  quite  sufficient  magni- 
tude to  give  us  very  positive  and  very  safe  conclusions  ; 
nor  but  that,  "  if  syphilis  could  be  diffused  by  the  vaccine 
lymph  of  children  with  an  hereditary  taint  of  that  dis- 

*  Papers  relating,  etc.  (op.  cit.),  p.  321-17. 


342  HANDBOOK  OF   VACCINATION. 

ease,  this  possibility  must  long  ago  have  been  made 
evident  on  a  scale  far  too  considerable  for  question.  "* 

Assuredly,  however,  neither  our  great  medical  au- 
thorities, nor  the  profession  generally,  have  arrived  at 
the  conviction  so  almost  unanimously  hitherto  enter- 
tained by  them,  of  the  non-communicability  of  syphilis 
by  vaccine  lymph,  solely  because  there  were  no  well- 
established  cases  of  such  communication  having  taken 
place  in  the  ordinary  process  of  vaccination.  They  re- 
lied also  on  the  teachings  of  pathology,  and  of  direct 
experiment. 

(b)  Nor  by  Pathological  Considerations.  —  Profes- 
fessor  Paget  states  the  pathological  grounds  for  disbe- 
lieving the  possibility  of  communication  of  syphilis  by 

*  Simon,  Preface,  etc.  {op.  eit.),  p.  lxvi.  But  suppose  (as 
we  should  have  to  do  if  we  were  to  accept  unreservedly  a 
number  of  statements  that  have  been  made)  that  to  impart 
syphilis  by  vaccination  it  is  not  necessary  that  the  child 
yielding  lymph  should  at  the  time  have  any  manifestation  of 
syphilis  but  that  it  is  quite  enough  that  it  should  be  incu- 
bating that  disease, — or  much  more,  that  it  need  not  even  be 
incubating  syphilis,  nor  have,  either  before  or  at  the  time  of, 
or  at  any  time  after  the  lymph  was  taken  from  it,  any  indi- 
cation of  syphilis  whatever,  but  only  have  a  parent  not  then 
suffering  from  syphilis,  but  who  might  at  some  former  time 
have  had  it, — or  still  further,  that  it  should  itself  be  free  from 
syphilis,  and  remain  free,  and  its  parents  equally  free,  and  the 
child  from  whom  it  was  vaccinated  and  its  parents  equally  free 
(there  being,  in  short,  perfect  immunity  from  syphilis  as  far 
back  as  the  lymph  could  be  traced) :  suppose  all  this,  I  say, 
and  at  this  rate  the  whole  world  must  have  been  syphilized 
long  before  this.  The  argument  from  experience  not  only 
then  gains  immense  force,  but  becomes  indeed,  on  the  scale 
on  which  we  have  it,  in  my  opinion,  quite  unanswerable. 
Surely  this  is  the  sort  of  evidence  that  proves  too  much. 


OBJECTIONS  TO    VACCINATION.  343 

vaccine  lymph — supposing  always  that  it  is  the  un- 
mixed lymph  of  a  true  vaccine  vesicle — to  be  (1)  be- 
cause infantile  syphilis  (which  alone  need  be  here 
considered),  though  conveyable  in  some  instances  by 
its  own  peculiar  morbid  products,  does  not  render  the 
blood  of  the  patient  capable  of  directly  conveying  the 
disease ;  and  (2)  because,  if  the  blood  of  a  syphilitic 
child  could  so  modify  the  vaccine  disease  within  it  as 
that  the  vaccine  lymph  should  be  capable  of  conveying 
any  other  disease,  there  is  every  reason  to  believe  that 
the  vaccine  vesicle  formed  in  the  diseased  child  would 
be  modified  in  correspondence  with  the  modified  lymph. 
"All  pathological  researches,"  he  remarks,  " accumu- 
late the  evidences  of  the  constant  correspondence  be- 
tween the  material  in  the  blood,  on  which  each  specific 
disease  depends,  and  the  morbid  structure,  by  which 
each  is  manifested.  Thus  the  transformations  of  syphi- 
litic poison  are  indicated  in  the  successive  external 
characters  of  the  primary,  secondary,  and  tertiary  af- 
fections ;  the  transformation  of  the  scarlatina  poison 
by  its  regular  symptoms  and  its  sequelae.  And  so,  if 
the  vaccine  virus  were  capable  of  any  transformations 
besides  those  which  mark  its  regular  influence  in  each 
patient,  such  transformations,  we  may  be  sure,  would 
be  indicated  by  corresponding  and  evident  changes  in 
the  vaccine  vesicle.  In  other  words,  if  the  vaccine 
were  changed  into  any  other  virus,  there  would  be  no 
vaccine  vesicle."*  The  opinions  of  Hebra,  and  other 
distinguished  pathologists,  are  equally  opposed  to  the 
possible  communication  of  any  other  infection  with 
vaccine  lymph.     Who  ever  heard,  in  fact,  of  the  virus 

*  Papers  relating,  etc.,  p.  139. 


344  HANDBOOK  OF  VACCINATION. 

of  small-pox  producing  anything  besides  small-pox? 
or  the  virus  of  measles  anything  besides  measles  ?  If 
eases  should  be  alleged  to  show  that  they  did  so,  let 
anybody  ask  himself  what  amount  of  evidence  he 
would  require  to  establish  the  point :  whether  it  would 
not  be  infinitely  more  reasonable  to  conclude  that  there 
were  fallacies  in  the  cases,  though  we  might  not  be 
able  to  point  them  out,  than  that  an  event  should  have 
occurred  so  opposed  to  universal  experience. 

(c)  Nor  by  Experiment. — Direct  experiments  made 
on  a  large  scale,  at  various  times,  and  by  many  indi- 
viduals, have  led  in  every  single  instance  to  the  same 
conclusion.  Vaccination  with  lymph  taken  on  purpose 
from  syphilitic  subjects  was  experimentally  practiced 
quite  early  in  the  century :  and  the  experiments  have 
since  been  repeated  again  and  again  by  different  ob- 
servers. The  inoculations  of  this  kind  which  Culle- 
rier,  Taupin,  Heymann,  and  others  have  performed, 
have  been  very  numerous.  Within  the  last  half  dozen 
years,  and  since  the  communicability  of  syphilis  by 
vaccination  has  been  so  warmly  discussed,  occasion 
has  been  taken,  by  several  individuals,  further  to  re- 
peat them.  Unvaccinated  persons  who  happened  to 
be  suffering  from  chancre  have  been  vaccinated,  and 
vaccine  vesicles  raised,  in  close  contiguity  to  the 
chancre:  and  from  the  vesicles  so  raised  vaccinations 
have  been  performed.  But  never  has  it  happened,  on 
a  single  occasion,  that  syphilis,  or  that  any  other  result 
than  vaccinia,  has  followed  the  use  of  vaccine  lymph 
thus  purposely  taken  from  a  syphilitic  subject.*    Now, 

*  I  cannot  see  the  advantage,  in  experiments  of  this  kind, 
of  making  the  vesicles  close  to  the  chancres,  and  I  can  see  a 


OBJECTIONS  TO    VACCINATION.  345 

the  value  of  these  experiments  is  immense,  for  in  them 
we  know  exactly  under  what  conditions  we  are  acting 
— whether  the  vacciniferous  child  was  really  sj^philitic 
or  not,  whether  the  vaccine  vesicle  developed  on  it 
were  a  regular  vaccine  vesicle  or  not,  whether  the 
lymph  used  was  mixed  or  not  mixed  with  syphilitic 
products,  whether  it  was  mixed  or  not  mixed  with 
syphilitic  blood.  The  difficulties  with  regard  to  these 
points  that  surround  our  inquiries  when  a  vaccinal 
origin  is  ascribed  to  a  syphilitic  case  are  so  great,  the 
fallacies  to  which  we  are  always  exposed  in  our  at- 
tempts to  discover  the  real  origin  of  cases  of  syphilis 
when  an  unusual  origin  is  suggested  are  so  great,  that 
cases  of  alleged  vaccinal  syphilis  become,  "  in  contrast 
with  experimental  results,  almost  valueless  for  instruc- 
tion." Is  it  credible  that,  if  syphilis  were  inoculable 
through  vaccine  lymph,  it  should  not  have  been  inoc- 
ulated on  any  one  of  these  really  innumerable  occa- 
sions ?  It  is  not  as  though  the  syphilitic  virus  were 
one  to  which  the  human  system  had  any  repugnance : 
the  exceeding  facility  with  which  it  is  inoculable  is 
well  known.  Nor  would  analogy  lead  us  to  suppose 
that  syphilis  could  be  thus  conveyed.  Taupin  and 
others,  in  their  experimental  inoculations  from  diseased 
subjects,  used  lymph  taken  from  persons  affected  with 
various  other  contagious  diseases  besides  syphilis  ;  but 
not  one  of  these  diseases  were  they  able  to  communi- 
cate through  the  lymph.     From  the  earliest  days  of 

great  disadvantage  in  the  risk  that,  in  taking  the  products  of 
the  vaccine  vesicles  for  further  experiments,  some  of  the 
syphilitic  virus  might  accidentally  get  mixed  with  the  vac- 
cine lymph,  and  thus  lead  to  syphilitic  results  and  to  most 
fallacious  conclusions. 

30 


346  HANDBOOK  OF   VACCINATION. 

vaccination  it  has  been,  moreover,  a  matter  of  familiar 
knowledge,  a  matter  to  which  I  have  before  had  occa- 
sion to  advert  (§  36,  p.  85),  that  if  lymph  be  taken 
from  a  vaccine  vesicle  in  a  patient  suffering  from  va- 
riola, with  due  care  to  procure  it  from  the  vaccine  vesi- 
cle only,  and  unmixed  with  the  products  of  any  of  the 
variolous  vesicles,  nothing  but  vaccinia  is  ever  pro- 
duced. "  Since,  then,"  says  Simon,  "  it  is  a  quite  un- 
questionable certainty  that,  even  when  the  system  is 
drenched  with  that  subtlest  infection  of  small-pox,  the 
Jennerian  vesicle  preserves  its  own  contagion  pure  and 
isolated,  the  argument  may  reasonably  be  extended. 
And,  even  if  there  were  no  evidence  in  relation  to 
other  diseases,  this  analogy  would  have  rendered  it 
eminently  improbable  that  any,  the  most  infectious,  of 
their  number,  could  admix  its  contagion  with  the  spe- 
cific products  of  cow-pox.  Indeed,  so  definitely  and  so 
constantly  characterized  are  those  local  changes  which 
different  morbid  poisons  severally  and  specifically  pro- 
duce, that  to  say  of  a  given  phenomenon,  'this  is  a 
typical  Jennerian  vesicle,'  is,  I  believe,  tantamount  to 
saying  this  is  a  vesicle  which  only  one  unmodified  in- 
fluence can  produce,  which  no  second  influence  can 
concur  in  producing,  and  in  the  contagion  of  which  no 
second  principle  of  infection  can  possibly  reside."* 

(d)  Of  course  Insertion  of  the  matter  of  Syphilis 
will  produce  Syphilis.  The  harmlessness  of  Vac- 
cination is  dependent  on  due  care  being-  used. — 
Whatever  conclusions  have  at  any  time  been  arrived 
at  with  regard  to  the  non-communicability  of  syphilis 
by  vaccination,  have  proceeded  always  on  the  assump- 

*  Simon,  Preface,  etc.  {pp.  cit.),  p.  lxiii. 


OBJECTIONS  TO    VACCINATION.  34? 

tion,  not  only  that  vaccine  lymph  was  used  (without 
which,  of  course,  there  could  have  been  no  vaccina- 
tion), but  that  it  was  pure,  unmixed  vaccine  lymph. 
If  the  matter  of  syphilis,  or  of  any  other  inoculable 
disease,  were  used,  accidentally,  instead  of  vaccine 
lymph,  who  could  doubt  that  syphilis,  or  the  disease, 
the  material  of  which  had  been  used,  would  be  the 
disease  produced?  If  the  matter  of  syphilis  were 
mixed  with  vaccine  lymph,  we  had  positive  experi- 
ment to  prove  to  us  that  syphilis  would  result.  And 
if  a  lancet  that  had  been  used  for  syphilization,  or  had 
become  in  any  way  contaminated  with  the  matter  of 
syphilis,  and  not  properly  cleaned,  were  used  for  vac- 
cinating, there  would,  of  course,  be  the  same  liability 
to  communicate  syphilis.  Malpractice  in  performing, 
or  in  attempting  to  perform,  vaccination  is  one  thing: 
the  communication  of  syphilis  by  vaccine  lymph  is 
another  thing.  Obvious  as  the  distinction  is,  it  seems 
very  necessary  to  insist  upon  it,  because  instances, 
that  were  well  known  and  had  never  been  denied,  of 
culpable  carelessness  in  attempting  to  vaccinate,  have, 
in  recent  discussions,  been  made  much  of,  as  though 
they  exhibited  the  results  of  the  real  and  proper  per- 
formance of  vaccination.  There  is,  however,  one  re- 
spect, and  a  very  important  one,  in  which  recent  facts 
appear  to  correct  views  previously  entertained  as  to 
the  effects  of  mixed  syphilitic  and  vaccine  viruses.  So 
far  as  experiments  had  gone,  they  had  led  us  to  believe 
that  whenever  a  mixture  of  the  two  viruses  was  used, 
the  compound  fluid  would  produce  syphilis,  certainly, 
but  would  not  produce  vaccinia:  that  syphilis  in  its 
inoculable  form  prevented,  within  the  sphere  of  its  in- 
fection, the  formation  of  a  vaccine  vesicle.     In  experi- 


348  HANDBOOK  OF   VACCINATION. 

ments  with  such  a  mixture,  made  by  Sigmund  and 
Friedinger,  nothing  but  syphilis  was  ever  produced.* 
Professor  Boeck,  also,  in  his  experiments  on  the  syph- 
ilization  of  children,  frequently  mixed  vaccine  lymph 
with  the  syphilitic  matter,  but,  like  Sigmund,  never  ob- 
tained any  but  syphilitic  results ;  and  the  children 
were  afterward  successfully  vaccinated  in  the  usual 
way.f  In  the  details  of  one  of  Friedinger's  experi- 
ments, however,  the  pustules  which  arose  from  the 
inoculation  of  the  mixture  were  noticed  as  presenting 
in  their  development  some  analogy  with  a  vaccine  pus- 
tule (vesicle)  ;J  but  on  this  kind  of  appearance  no 
stress  was  laid  by  him,  nor  indeed  ought  to  be  laid,  as 
it  might  have  occurred  even  if  unmixed  syphilitic 
matter  had  been  employed,  for  we  have  Ricord's  au- 
thority that  a  chancrous  pustule,  "  initial  lesion  of  the 
primary  syphilitic  ulcer,  when  it  develops  itself  on  the 
skin,"  has  characters  which  may  readily  cause  it  to  be 
confounded  with  the  vaccine  pustule. §'  Similar  experi- 
ments made  by  Bauines  and  Sperino  resulted,  like  those 
of  Friedinger,  always  in  the  development  of  syphilis, 
but  produced  also,  in  one  case,  what  appeared  to  them 
to  be  like  a  vaccine  effect;  and  as  this  case  is  cited  by 
M.  Viennois||  as  proving,  in  his  opinion  in  the  clearest 

*  Simon,  Preface,  etc.  (op.  cit.),  p.  lxv. 

f  De  la  Syphilis  Vaccinale  (Paris,  1865),  p.  386.  This  is  a 
report  of  the  discussions  which  took  place  in  the  Acad.  Imp. 
de  Med.  on  this  subject  in  1864,  together  with  a  reprint  of 
various  papers,  including  the  very  able,  interesting,  and  com- 
prehensive essays  of  M.  Viennois. 

+  De  la  Syphilis  Vacc.  (op.  cit),  p.  277. 
§  Diday,  Treatise  on  Syphilis,  translated  by  Whitley   (New 
Syd.  Soc.),p.  54. 

||  De  la  Syph.  Vacc.  (op  cit),  p.  280. 


OBJECTIONS   TO    VACCINATION.  349 

way  ("de  la  facon  la  plus  nette"),  that  both  vaccinia 
and  chancre  were  communicated  together,  it  is  of  the 
utmost  importance  to  note  what  those  results  were. 
The  subject  of  this  experiment  was  a  young  woman, 
who  had  never  been  vaccinated  or  had  small-pox,  and 
the  account  of  the  phenomena  produced  by  the  inocu- 
lation with  the  mixed  viruses  of  chanchre  and  vaccine, 
given  by  M.  Baumes,  is  as  follows :  "  Des  le  debut  les 
pustules  ont  offert,  d'une  maniere  sensiblement  predo- 
minante,  le  caractere  vaccinal.  .  .  .  Le  troisieme  jour, 
au  point  011  les  piqures  avaient  ete  pratiquees,  appa- 
raissent  de  petits  cercles  enflammes,  rouges,  fonces, 
assez  circonscrits,  avec  sensation  de  durete  au  tact;  le 
quatrieme  jour,  un  point  central  sedessine  en  forme  de 
pustule  par  le  soulevement  de  l'epiderme,  refermant 
au-dessous  une  matiere  moins  claire,  moins  opaline, 
que  le  fluid-vaccin,  et  se  rapprochant  deja  ce  jour  la  et 
beaucoup  plus  le  lendemain,  de  la  couleur,  de  la  consist- 
ance  de  la  matiere  propre  a  la  pustule  variolique  et  a 
la  pustule  chancreuse ;  le  sixieme  jour,  toutes  les  pus- 
tules sont  bicn  formees,  nettement  dessinees,  aplaties, 
largement  ombiliquees,  avec  cercle  rouge  fonce,  d'un 
aspect  cuivreux,  gonflement  du  derme ;  le  septieme  et 
le  huitieme  jour,  la  dimension  des  pustules  d'inflam- 
mation  augmeute  ;  de  fortes  douleurs,  melees  de  deman- 
geaisons,  se  font  sentir;  la  malade,  par  le  frottement 
ou  en  se  grattant,  rompt  les  pustules ;  celles  restees  in- 
tactes  sont  dechirees  par  la  lancette  pour  l'inoculation 
du  pus  chancreux  a  d'autres  malades."  A  vaccination 
performed  on  this  young  woman,  two  days  afterward, 
with  lymph  taken  from  the  arm  of  a  child,  produced  no 
effect.  If  this  be  indeed  a  case  of  vaccino-syphilitic 
inoculation,  of  the  production  of  the  two  diseases  by 
30* 


350  HANDBOOK  OF    VACCINATION. 

the  same  operation,  if  in  the  peculiarity  of  pustule 
noted  from  the  fourth  to  the  sixth  day  the  action  of  the 
vaccine  virus  was  manifested,  it  was  surely  a  case  of 
most  irregular  vaccination,  one  which  exactly  bears 
out,  and  exceedingly  well  illustrates,  the  statement  of 
Paget  that  if  any  other  virus  were  working  locally 
along  with  vaccine  lymph,  there  would  be  correspond- 
ent and  evident  changes  in  the  character  of  the  vac- 
cine vesicle.  Pus  taken  from  the  pustules  in  this  case 
on  the  eighth  day  communicated  chancres  only.  What 
would  have  been  the  effect  of  matter  taken  from  them 
two  or  three  days  earlier  ?  I  cannot  say.  Possibly 
some  remains  of  the  vaccine  virus  might  have  caused 
some  spurious  results  of  vaccinia  to  be  manifested. 
But  if  M.  Viennois,  in  citing  this  as  a  typical  case  of 
vaccinia  transmitted  along  with  chancre,  means  that 
vaccine  lymph,  such  as  might  properly  be  used  in  vac- 
cinating, could  be  got  from  such  pustules  as  these, 
there  would  surely,  where  such  doctrines  were  held, 
be  an  easy  way  of  accounting  for  any  amount  of  acci- 
dents * 

*  I  am  not  personally  acquainted  with  the  practice  of  vac- 
cination in  France  and  Italy,  but  the  accounts  one  reads  of  it 
are  not  of  a  nature  to  give  much  confidence  as  to  the  manner 
in  which  a  good  deal  of  it  is  performed.  It  seems  to  have 
been  withdrawn,  to  a  large  extent,  from  professional  care, 
and  to  have  been  handed  over  to  farriers  and  midwives.  It  is 
a  common  thing  to  read  of  the  same  child  being  used  two  or 
three  days  running  for  yielding  lymph,  and  of  fifty,  sixty,  or 
a  hundred  children  being  vaccinated  off"  it!  In  one  case  104 
children  were  vaccinated  from  the  same  child  on  three  differ- 
ent days!  What  the  kind  of  vesicles  are  from  which  this 
lymph  is  taken  I  cannot  say.  In  professional  hands  there 
would  be  no  fear  in  England  of  anything  being  taken  from 


OBJECTIONS  TO    VACCINATION.  351 

On  the  other  hand,  there  is  no  reason  that  one  can 
see  why  the  inoculable  materials  of  two  different  infec- 
tions, each  having  a  different  period  of  incubation, 
should  not  if  inserted  together  produce  each  its  own 
specific  results.  If  the  two  contagions  were  simul- 
taneously inoculated  on  different  parts  of  the  skin,  there 
can  be  no  doubt,  I  apprehend,  that  such  would  be  the 
consequence;  and  the  like  might  not  unreasonably  be 
expected  to  occur  if  they  were  mixed  and  inserted  to- 
gether on  the  same  part  of  the  skin.  The  whole  course 
of  vaccinia  is  over  in  about  three  weeks,  or  before, 
according  to  its  law  of  incubation,  the  virus  of  syphilis 
begins  to  manifest  its  local  action ;  and  in  this  way 
(though  as  yet  intentional  experiments  have  not  so 
demonstrated)  the  two  diseases  might  possibly  be  im- 
planted together.  In  some  such  result  of  an  accidental 
and  undesigned  experiment  exists  certainly  the  most 
probable  explanation  of  one  or  two  occurrences  in  which 
there  seems  authentic  evidence  of  regular  vaccinia  and 

any  pustules  like  those,  e.g.  described  *n  the  text;  but  who 
shall  say  what  might  not  be  taken  by  ignorant  people  profess- 
ing to  vaccinate?  It  is  not  many  years  ago  that  I  saw  a  drug- 
gist, who  had  in  his  time  done  a  good  deal  of  vaccination, 
about  to  vaccinate  some  children  (and  but  for  my  interference 
he  would  have  vaccinated  them)  with  matter  taken  from  an 
open  sore  on  the  arm  of  a  child,  on  which  there  was  not  a  ves- 
tige of  a  vaccine  vesicle  having  ever  been,  but  which  he  as- 
sumed to  be  vaccine  because  he  had  vaccinated  the  child  on 
that  spot  on  the  arm  the  week  before.  It  should  in  justice  be 
stated  that  the  practices  above  adverted  to  in  the  performance 
of  vaccination  in  France  and  Italy  have  come  to  light  in 
reference  to  the  accidents  which  (and  no  wonder)  have  fol- 
lowed ;  and  may  by  no  means  fairly  represent  the  way  in 
which  vaccination  generally  is  carried  on  in  those  countries. 


352  HANDBOOK  OF    VACCINATION. 

of  syphilis  being  received  at  the  same  operation.  A 
scandalous  transaction  of  this  kind  took  place  some  two 
years  ago,  at  the  Academie  Imperiale  de  Medecine  at 
Paris,  when,  the  director  of  the  vaccinations  being  ab- 
sent, the  day's  vaccinations  were  left  to  a  mere  employe 
of  the  establishment,*  who  took,  it  was  found  afterward, 
the  material  with  which  he  performed  a  certain  portion  of 
these  vaccinations  from  a  child  covered  with  syphilitic 
eruptions  and  ulcerations,  and  in  such  an  advanced 
state  of  the  disease  that  it  died  the  day  following.  In 
eight  out  of  nine  children  operated  on  from  this  source, 
vaccine  vesicles  appear  to  have  been  developed,  and  in 
all  the  nine  unequivocal  syphilis  manifested  itself  after- 
ward. No  direct  evidence  is  of  course  obtainable  as  to 
what  the  material  used  for  these  vaccinations  really 
was.  But  which  is  the  more  likely,  having  regard  to 
the  results  which  have  attended  every  one  of  the  innu- 
merable experiments  in  which  lymph  has  been  taken 
from  syphilitic  children,  but  in  which  there  was  no  ad- 
mixture of  syphilitic  products, — that  the  lymph  he 
used  was  so  mixed,  V  that  it  was  mere  lymph  ?  There 
was  in  this  case  every  facility  for  such  careless  mixture. 
But  as  in  twofold  inoculations  of  this  kind  the  two  in- 
fections acting  each  within  its  period  of  incubation 
would  take  quite  independently  one  of  the  other,  what- 
ever lymph  might  be  extracted  on  the  eighth  day  from 
a  vesicle  having  the  character  of  a  normal  vaccine  vesi- 
cle, would  of  course  convey  nothing  but  the  vaccine 
infection.  In  18G2,  five  out  of  six  children  vaccinated 
at  Torre  del  Busi,  by  M.  Quarenghi,  with  some  stuff 

*  "Was  it  the  individual  whose  qualifications  are  described 
at  p.  206  ? 


OBJECTIONS  TO    VACCINATION.  353 

in  a  tube  which  had  been  lying  by  for  six  months,  first 
went  through  vaccinia  in  the  usual  way,  and  had  after- 
ward syphilitic  symptoms  of  so  infectious  a  kind  that 
their  mothers  and  nurses,  and  those  who  handled  them, 
or  fed  with  the  same  spoons  as  they  used,  were  syphi- 
lized ;  but  yet  these  children  on  the  eighth  day  of  their 
vaccination  transmitted  nothing  but  vaccine,  without 
any  trace  of  syphilis,  to  the  children  who  were  vaccin- 
ated from  them.* 

(e)  Question  of  Accidental  Inoculation  of  Syphilis 
by  the  Blood. — If,  again,  syphilis  be  inoculable  through 
the  blood,  inoculation  of  the  blood  of  a  syphilitic  sub- 
ject along  with  vaccine  lymph  might  readily  be  sup- 
posed capable  of  conveying  with  it  the  syphilitic  infec- 
tion. And  this  is  indeed  the  explanation  usually 
offered  of  cases  in  which  some  have  held  that  both  vac- 
cinia and  syphilis  were  communicated  by  the  same  oper- 
ation, but  in  which,  according  to  accounts,  the  vaccin- 
iferous  child  was  not  at  the  moment  the  subject  of  any 
external  syphilitic  manifestation  —  was  in  fact  only 
incubating  the  disease.  M.  Viennois,  who  strongly 
holds  the  opinion  that  syphilis  may  be  implanted  with 
vaccinia  under  such  circumstances,  does  not  imagine 
this  to  take  place  through  the  vaccine  lymph,  and  gives 
indeed  very  sufficient  reasons  why  this  should  not  be 
so;  but  he  holds,  and  H.  Lee  and  others  follow  him, 
that  the  blood  may  act  like  one  of  the  inoculable  pro- 
ducts of  syphilis  would  do  in  infecting  the  system.  No 
doubt  this  is  infinitely  more  probable  than  that  vaccine 
lymph  should  be  an  agent  of  such  infection ;  but  yet 
when  we  reflect  (1)  that  no  proof  has  ever  yet  been  ad- 

*  De  la  Syph.  Vacc,  p.  303  seq. 


354  HANDBOOK  OF   VACCINATION. 

duced  by  direct  experiment  of  the  communicability  of  in- 
fantile (or  hereditary)  syphilis  by  blood-inoculation  ;* 
(2)  that  the  inoculation  by  the  blood,  of  the  acquired 
syphilis  of  an  adult  has  been  found,  in  direct  experiments, 
to  be  a  matter  of  very  great  difficulty,  requiring  for  suc- 
cess (when  it  is  attained)  the  exposure  of  a  very  large 
absorbent  surface ;  and  (3)  that,  in  the  vaccinations 
which  must  in  the  course  of  seventy  years  have  taken 
place  accidentally  from  syphilitic  children  times  innu- 
merable, blood  must  often  have  been  invaccinated,  and 
that  in  many  of  the  experimental  vaccinations  from 
syphilitic  children  either  no  care  was  taken  to  exclude 
blood,  or  blood  was  purposely  mixed,  and  yet  no  syphilis 
resulted  :f  we  are  justified,  I  think,  in  requiring  very 
clear  evidence  indeed  before  we  can  admit  that  syphilitic 
infection  can  be  communicated  wholesale  by  the  blood 
which  might  enter  in  an  ordinary  carelessly-performed 

*  In  all  the  alleged  cases  of  communication  of  syphilis  in 
vaccinating,  the  lymph  was  taken  from  a  child,  except  in  the 
cases  of  J.  Lecocq :  but  Lecocq's  cases  are  very  inconclusive 
(see  post).  Heim  in  some  of  his  experiments  took  the  lymph 
from  adults,  hut  no  syphilis  followed.  (Historisch-Kritische 
Darstellung  der  Pockenseuchen,  p.  613.) 

f  Cullerier  particularly  mentions  that  his  experiments  were 
made  without  any  special  precaution  (Gaz.  des  Hopitaux,  1862, 
p.  99);  and  Boeck  mixed  the  syphilitic  blood  of  a  child  on  pur- 
pose with  its  own  vaccine  lymph,  and  performed  with  the 
mixture  two  revaccinations ;  vaccine  effect  was  produced  in 
one  of  the  cases,  but  no  syphilis  in  either.  (De  la  Syphilis 
Vaccinale,  p.  386.)  In  conducting  an  ordinary  vaccination, 
it  has  ever  been  the  mark  of  a  slovenly  and  careless  vaccinator 
to  allow  any  blood  to  be  mixed  with  the  lymph  used ;  but  still 
I  do  not  think  that  it  occurred  to  many  to  suppose — at  all 
events  before  the  recent  discussions — that  there  was  in  the 
mixture  any  risk  of  conveying  extraneous  infection. 


OBJECTIONS  TO    VACCINATION.  355 

vaccination,  as  in  some  of  the  cases  alleged — evidence, 
I  will  venture  to  say,  after  a  careful  study  of  these 
cases,  far  stronger  than  has  yet  been  adduced  in  any 
one  of  them. 

(f)  Consideration  of  Cases  of  Alleged  Vaccino- 
Syphilitic  Inoculation Cases  which  had  been  sup- 
posed to  show  that  syphilis  might  be  introduced  into 
the  system  by  means  of  vaccination  date  back  to  a  very 
early  period  of  the  century.  They  were,  however,  so 
few  in  number — the  medical  literature  of  sixty  years 
being  unable,  when  ransacked,  to  furnish  more  than  a 
dozen  occasions  on  which  such  an  event  was  supposed 
to  have  occurred — and  these  when  examined  were 
found  to  depend  so  much  on  hearsay  and  doubtful 
evidence,  and  to  be  so  open  on  all  sides  to  fallacies, 
that  they  had  done  little  to  shake  the  belief,  entertained 
till  a  few  years  ago  by  the  whole  profession  at  home 
and  abroad,  with  very  rare  exceptions,  that  the  two 
diseases  would  not  pass  into  the  system  together.  If 
vaccinia  passed,  it  would  be  vaccinia  only.  If  syphilis 
passed  (which  of  course,  as  then  held,  could  not  be 
without  the  substitution,  or  the  admixture,  of  syphilitic 
matter),  it  would  be  syphilis  only.  I  have  already 
stated  how  far,  in  my  opinion,  this  belief  as  to  the  im- 
possibility of  introducing  the  two  diseases  at  one  time, 
if  the  inoculable  products  of  both  are  used,  may  be  open 
to  correction  But  such  were  certainly  the  opinions 
generally  Entertained,  till,  in  1861,  some  occurrences 
which  took  place  in,  Italy  and  France  caused  the  whole 
question  of  the  invaccination  of  syphilis  to  be  reopened 
for  discussion.  The  event  in  Italy  was  an  outbreak  of 
endemic  syphilis  at  a  little  village  called  Kivalta, 
clearly  traceable,  it  was  said,  to  a  vaccinal  origin ;  the 


356  HANDBOOK  OF   VACCINATION. 

event  in  Prance  was  the  occurrence,  in  the  wards  of  M. 
Trousseau  at  the  Hotel-Dieu,  in  Paris,  of  a  case  which 
gave,  it  was  said,  direct  proof  of  a  vaccine-syphilitic 
inoculation.  It  so  happened  that,  at  the  time  these 
events  occurred,  the  medical  profession  in  France  was 
much  divided  between  two  rival  schools  of  syphilogra- 
phers,  and  that,  from  the  intimate  bearing'  which  the 
vaccinal  inoculation  of  syphilis,  if  shown  to  be  possible, 
would  have  on  the  points  in  dispute,  a  very  large  party 
existed  not  only  ready,  but  apparently  eager,  to  accept 
any  evidence  of  it.  A  discussion  began  within  the  walls 
of  the  Academie  which  is  not  yet  terminated,  nor  is 
likely  soon  to  be  terminated.*  In  the  course  of  it 
every  case  then  on  record  was  brought  out  for  recon- 
sideration. Other  alleged  cases  of  subsequent  occur- 
rence have  since  been  added.  And  there  is  now  a 
party  there  who  maintain  that  by  vaccination  (meaning 
thereby  vaccination  performed  with  the  lymph  of  a  gen- 
uine Jennerian  vesicle)  from  a  subject  who  has  any 
syphilitic  taint,  and  even  from  subjects  who,  so  far  as 
evidence  can  determine,  are  free  from  any  such  taint 
themselves,  and  are  derived  from  parents  who  have  no 
such  taint,  syphilis  may  be  communicated!  The  Aca- 
demie, as  a  body,  is  far  from  having  indorsed  these 

*  The  patient  reader  of  these  discussions  (and  it  requires 
some  patience  to  read  the  whole  of  them)  will  see  that  I  have 
not  misrepresented  their  spirit.  The  vaccinal  inoculation  of 
syphilis,  as  it  is  called,  is  hailed  in  a  sort  of  jubilant  tone 
ns  giving  the  "  dernier  coup"  to  a  certain  "  6cole  syphilogra- 
phique."  Personalities  abound,  and  are  not  even  excluded  from 
the  Official  Keport,  or  rather  "Projet  de  Rapport,"  drawn  up 
by  M.  de  Paul  for  presentation,  according  to  custom,  to  the 
Ministre  de  1' Agriculture,  etc.,  but  not  accepted  by  the 
Academie. 


OBJECTIONS  TO    VACCINATION.  35 \ 

opinions  In  Germany  and  in  England,  the  inquiry 
has  been  taken  up  in  a  much  more  sober  spirit,  but  cer- 
tainly with  no  less  determination  to  arrive  at  the  truth. 
The  necessity  of  reviewing  the  whole  subject  has  been 
fully  recognized,  but  it  has  also  been  clearly  seen  that 
when  we  are  called  on  to  accept,  on  the  ground  of  cer- 
tain alleged  facts,  conclusions  which  are  opposed  to  all 
that  pathology  and  experience  had  heretofore  taught  us, 
we  ought  to  satisfy  ourselves  not  only  that  these  facts 
rest  on  sufficient  testimony,  but  that  they  comprehend 
everything  necessary  for  a  complete  judgment,  and  that 
no  other  interpretation  of  them  is  possible.* 

Among  the  sources  of  fallacy  against  which  we  have 
to  be  on  our  guard  in  cases  in  which  syphilis  has  been 
said  to  have  been  produced  by  vaccination,  one  is  an 
erroneous  diagnosis.  Persons  talk  very  glibly  about 
sores  being  syphilitic  and  eruptions  being  syphilitic, 
as  though  the  characters  of  syphilitic  sores  and  syphi- 
litic eruptions  were  so  made  out  that  there  could  never 
be  any  mistake  about  them.  Yet  such  mistakes  are 
daily  being  made  by  practitioners  in  general,  and  are 
occasionally  made  by  the  very  highest  authorities. 
About  four  years  ago  one  of  those  among  us  most 
conversant  with  syphilis,  Mr.  Henry  Lee,  announced 
to  the  Medico-Chirurgical  Society  that  he  had  a  case 

*  As  M.  Briquet  has  well  pointed  out,  a  competent  observer, 
and  a  complete  observation,  reported  with  such  detail  as  renders 
the  statements  capable  of  being  checked  by  the  reader,  are  indis- 
pensable requisites  for  establishing  the  reality  of  an  ordinary 
fact  in  medicine  ;  and  if  for  establishing  an  ordinary  fact,  how 
much  more  when  the  facts  alleged  are  confessedly  so  rare  and 
so  contrary  to  all  previous  experience  as  these  must  be  ad- 
mitted to  be. 

31 


358  HANDBOOK  OF   VACCINATION. 

under  his  care  in  which  a  syphilitic  chancre  had  been 
produced  on  the  arm  of  a  child  by  vaccination.  The 
case  was  seen  by  many  members  of  the  profession, 
some  of  whom  agreed  with  Mr.  Lee,  while  others  saw 
nothing  but  a  sore  arm,  the  result  of  a  degenerated 
vaccine  vesicle.  The  subsequent  progress  of  the  case 
quite  satisfied  Mr.  Lee  that  he  had  been  mistaken  in  his 
diagnosis,  as  he  publicly  acknowledged.*  Acton  tells 
us  that  he  has  repeatedly  seen  eczema,  lepra,  and  papu- 
lar eruptions  in  children  ascribed  to  a  syphilitic  taint, 
which  were  after  all  eruptions  of  a  simple  non-specific 
kind.  And  assuredly  I  have  on  various  occasions 
myself  known  (quite  apart  from  any  connection  or 
supposed  connection  with  vaccinia)  eruptions  called 
syphilitic,  for  no  other  reason  than  that  they  were 
intractable,  and  had  something  of  a  dusky  color.  In 
all  alleged  cases  of  post-vaccinal  syphilis  great  care 
must  be  taken  in  the  first  instance  with  regard  to  the 
diagnosis. 

But,  supposing  the  diagnosis  established,  the  next 
point  is  to  ascertain  the  origin.  Now  there  is  no 
medical  practitioner  who  needs  to  be  told,  and  no 
medical  student  can  be  long  in  finding  out,  that,  of  all 
subjects  of  medical  inquiry,  the  ascertainment  of  the 
origin  of  individual  cases  of  syphilis  is  one  of  the  most 
perplexing  and  the  most  encumbered  with  fallacies. 
Hereditary  syphilis  (unfortunately  not  uncommon)  is 
yet  generally  not  willingly  admitted  by  either  one  or  the 
other  parent.     Its  symptoms  do  not  manifest  them- 

*  A  case  looked  on  at  first  as  very  doubtful,  but  recognized 
afterward  to  be  a  simple  sore  arm,  was  met  with  by  MM. 
Bergeron  and  Cullerier.     (De  la  Syphilis  Vaccinale,  p.  48.) 


OBJECTIONS   TO    VACCINATION.  359 

selves  usually  till  some  weeks,  and  in  exceptional  cases 
not  till  some  months,  after  birth ;  and  if  in  the  mean- 
while vaccination  should  have  been  performed,  what  so 
convenient  as  that  it  should  be  put  forward  as  the 
cause  ?  Nor  is  it  by  any  means  impossible  that,  in 
children  with  hereditary  taint,  the  vaccination  might, 
by  its  momentary  derangement  of  the  health,  actually 
have  been  the  means  of  first  evolving  the  disease ;  or 
that  in  some  in  whom  the  disease  had  alreadymani- 
fested  itself  before  vaccination,  but  had  disappeared  on 
treatment,  the  vaccination  might  be  the  means  of  again 
evolving  it.  This  we  know  may  be  done  by  the  clean 
cut  of  a  surgical  knife  used  in  an  ordinary  operation, 
and  presumably,  therefore,  might  happen  "at  the  vac- 
cine punctures  of  a  child  having  latent  constitutional 
syphilis.  Under  the  operation  of  this  constitutional 
taint  they,  or  one  of  them,  might  become  the  seat  of 
secondary  syphilitic  ulceration,  and  greatly  perplex 
any  observer  in  ignorance  of  the  real  cause;  especially, 
of  course,  if  the  parents  were  endeavoring  to  disguise 
the  previous  facts  of  the  case.*     Where  syphilis  in 

*  "  Some  years  ago  I  performed  on  a  little  boy,  having  no 
apparent  ill  health,  a  very  trifling  surgical  operation — that  for 
phimosis.  In  a  few  days  the  incision  was,  as  is  usual,  all  but 
well.  In  a  few  more  it  had  begun  to  ulcerate.  For  some 
weeks  there  continued  in  the  part  an  indolent  inflammatory 
process,  with  considerable  swelling,  and  slow  but  progressive 
ulceration.  A  variety  of  treatment  failed  to  do  good.  At 
length  a  suspicion  occurred  to  my  mind  which  led  me  to  pre- 
scribe iodide  of  potassium.  Within  eight  and  forty  hours  the 
wound  had  thoroughly  changed  its  character — every  reason 
for  alarm  was  gone  ;  and  within  a  few  days  complete  healing 
was  accomplished.  I  now  learnt  that  the  child  had  been  born 
with   a  strong   hereditary  taint,  and   had — long   before  the 


360  HANDBOOK  OF   VACCINATION. 

children  is  really  acquired  we  know  that  there  are 
many  ways  in  which  this  may  be  brought  about;  from 
their  nurses,  from  the  persons  with  whom  they  sleep," 
etc.  etc. 

In  investigation,  then,  of  alleged  cases  of  vaccinal 
syphilis  we  have  to  ascertain  (1)  whether  we  are  really 
dealing  with  syphilis ;  (2)  whether,  if  this  be  so,  the 
syphilis  is  not  hereditary,  and  a  mere  coincidence  or 
evolution  of  the  vaccination ;  (3)  whether,  if  it  be  ac- 
quired syphilis,  this  has  not  some  other  origin,  uncon- 
nected with  the  vaccination  or  attempt  to  vaccinate; 
(4)  whether,  if  the  acquisition  of  the  syphilis  be  reason- 
ably traceable  to  the  vaccination  or  attempted  vaccina- 
tion, there  is  evidence,  direct  or  presumable,  that  the 
so-called  vaccination  had  been  done  from  a  genuine 
vaccine  vesicle,  and  that  the  products  of  that  vesicle 
had  not  been  mixed  with  some  of  the  inoculable  pro- 
ducts of  syphilis.  Not  till  all  this  was  settled  would 
any  question  arise  about  admixture  of  blood.  The 
interest  and  importance,  after  all,  of  the  cases  in  which 
vaccination  is  alleged  to  have  communicated  something 
besides  its  own  infection,  turn  entirely  upon  whether 
the  vaccination  had  been  performed  with  the  unmixed 
lymph  of  genuine  vesicles,  vesicles  about  which  no 
competent  person  would  make  a  mistake. 

It  must  obviously  be  impossible  to  discuss  at  length, 
within  such  limits  as  in  a  general  treatise  of  this  kind 
could  be  allowed,  all  the  cases  that  have  been  cited  as 
evidences  of  the  communicability  of  syphilis  by  vac- 
operation — required  constitutional  treatment  on  account  of 
the  usual  symptoms  of  infantile  syphilis."  (Simon,  Preface, 
op.  cit.,  p.  lxvi.,note.) 


OBJECTIONS   TO    VACCINATION.  361 

cination.  The  most  satisfactory  course  will  be,  I  think, 
to  examine  carefully  three  or  four  cases,  typical  of  the 
kinds  of  proof  which  have  been  advanced  of  this  occur- 
rence: but  the  reader  will  find  all  the  cases — at  all 
events,  all  on  which  any  stress  has  been  laid  by  the 
advocates  of  vaccino-syphilitic  inoculation — referred  to 
in  the  note  below.* 

*  Many  of  the  following  cases  had  been  long  known,  amply 
discussed,  and  set  aside  as  inconclusive,  at  the  time  when  the 
general  expression  of  medical  opinion  as  to  the  harmlessness 
of  properly  performed  vaccination,  before  referred  to  (p.  339), 
was  elicited  in  answer  to  the  inquiries  of  Mr.  Simon,  in  1856. 
(1)  An  endemic  of  syphilis  reported  by  Cerioli  as  having 
occurred  in  1821  [inquiry  made  eight  months  after  its  origin  ; 
the  account  given  of  this  endemic  is  of  the  loosest  kind ;  it 
was  not  proved,  or  even  alleged,  that  the  child  from  whom 
the  lymph,  supposed  to  have  been  the  origin  of  the  outbreak, 
was  taken,  had  ever  had  syphilis];  (2)  another  endemic  in 
1841,  seen  also  by  Cerioli  [investigated  likewise  after  a  very 
long  lapse  of  time  ;  the  child  from  whom  the  lymph  was  taken 
never  had  syphilis,  but  it  was  said  that  a  year  before  his  father 
had  had  syphilis — this  one  child  was  used  for  vaccinating  sixty- 
four  children,  living  in  four  communes] ;  (3)  cases  reported 
by  Pitton  in  1844  and  by  Ceccaldi  in  1845  [worth  referring  to 
as  showing  the  sort  of  evidence  which  some  practitioners  rely 
on  to  prove  vaccinal  syphilis,  but  not  cases,  it  should  be  said, 
to  which  M.  Viennois  attaches  any  importance;  he  points  out 
that  the  dates  are  inconsistent  with  the  syphilis  being  derived 
from  vaccination]  ;  (4)  cases  reported  by  M.  Vianit,  in  which 
two  adults  had  syphilis,  ascribed  to  revaccination,  from  a  little 
nephew  [details  quite  insufficient  for  any  complete  judgment]  ; 
(5)  case  of  the  Veterinaire  B.,  in  1850,  stated  at  length  in 
text ;  (6)  case  of  Hiibner,  in  1852,  also  referred  to  in  text ;  (7) 
a  case  at  New  York,  in  1854,  of  a  child  having  a  sore  on  the 
arm,  and  general  symptoms  believed  to  be  syphilitic,  said  by 
parents  to  have  been  from  vaccination  in  Ireland  (!);  (8)  the 
31* 


362  HANDBOOK  OF   VACCINATION. 

The  case  which  is  generally  cited  as  that  of  "  Le 
Veterinaire  B."  is  a  case  of  undoubted  communication  of 

cases  recorded  by  Mr.  Whitehead,  of  Manchester  [Mr.  White- 
head's book  was  published  some  time  before  Simon's  inquiry, 
but  in  none  of  his  cases  is  the  evidence  at  all  conclusive,  and 
very  little  weight,  I  believe,  has  ever  been  attached  to  them ; 
M.  Viennois  himself  rejects  all  of  them  but  four] ;  (9)  cases 
said  to  have  occurred  in  1856  in  an  Italian  village  to  Dr. 
Marone,  but  not  recorded  till  six  year  afterward  [not  till 
after  the  Kivalta  cases,  which  in  circumstances  they  resemble]  ; 
(10)  case  of  two  soldiers  vaccinated,  in  1859,  by  Jules  Lecocq 
[the  lymph  was  taken  from  an  adult,  who,  it  is  said,  three 
months  before  had  had  chancre,  but  had  quite  recovered ; 
other  persons  vaccinated  from  him  had  vaccinia  and  no 
syphilis,  but  these  two  had  no  vaccinia,  but  sores  on  the  arm, 
and  at  the  end  of  six  months  secondary  eruption.  In  one 
account,  given  by  Lecocq,  these  sores  are  said  to  have  begun 
on  the  fourth  day  of  the  vaccination,  in  another  account,  also 
by  him,  to  have  begun  on  the  eighth  day:  either  of  which 
dates  is  inconsistent  with  their  being  of  really  syphilitic  char- 
acter, and  the  origin  of  the  constitutional  affection  which  after- 
ward followed,  but  the  discrepancy  should  not  pass  unnoticed, 
as  showing  how  little  reliance,  in  a  matter  of  dates,  is  to  be 
placed  on  the  testimony  even  of  educated  and  professional 
persons,  when  given  from  mere  recollection.  How  much 
more,  then,  is  caution  requisite  in  accepting  the  statements  of 
ignorant  and  prejudiced  persons  as  to  dates,  and  sequence  of 
events,  relating  to  the  origin  and  progress  of  the  disease]  ;  (11) 
the  Rivalta  cases;  and  (12)  Trousseau's  case  [both  given  in 
text]  ;  (13)  cases  of  M.  Quarenghi  [also  referred  to  in  text]  ; 
(14)  three  cases  recorded  in  1863,  one  by  Chassaignac,  another 
by  Devergie,  and  another  by  Herard,  of  children  having  vac- 
cine vesicles,  and  afterward  syphilitic  sores  on  the  arms  [but 
in  each  of  these,  essential  particulars  with  regard  to  the  vac- 
cination are  wanting]  ;  (15)  case  of  two  children  vaccinated 
at  Alma  in  1863,  who,  according  to  the  very  cursory  account 
given,  had  vaccine  vesicles  first  and  syphilitic  sores  after- 


OBJECTIONS  TO    VACCINATION.  3G3 

syphilis  by  a  man  professing  to  vaccinate — one  of  the 
cases  of  culpable  carelessness  already  adverted  to — but 
so  far  from  being  a  case  of  syphilis  communicated  along 
with  vaccination,  the  account  affords  not  the  smallest 
pretext  for  asserting  that  there  was  ever  any  vaccina- 
tion at  all.  It  appears  that  in  a  town  in  Germany 
twenty-four  people  belonging  to  different  families  were 
in  February,  1849  (some  on  the  13th,  some  on  the  14th, 
and  some  on  the  15th),  revaccinated,  as  they  supposed, 
by  him.  There  is  no  statement  of  vaccine  vesicles  hav- 
ing been  produced  in  one  of  th£  cases,  but  at  the  end  of 

ward ;  (16)  case  reported  in  1864,  by  M.  Sebastian,  of  Beziers 
[a  case  brought  forward  to  show,  in  conjunction  with  some 
experiments,  that  blood  may  communicate  syphilis,  but  that 
lymph  will  not]  ;  (17)  the  cases  at  the  Academie  in  1865,  stated 
in  text;  (18)  statement  of  104  children  vaccinated  on  three 
different  days  off  the  arm  of  one  child  in  1866  by  a  midwife — 
all  of  them,  as  well  as  twenty-three  who  were  vaccinated  the 
week  following,  having  syphilis  [certainly  one  of  the  most 
extraordinary  cases  on  record.  A  case  unquestionably  of 
great  malpractice  in  vaccination  ;  but  whatever  symptoms 
these  children  had  that  were  taken  to  be  syphilitic,  they  all 
recovered — ninety-seven  of  them  who  had  no  treatment,  just 
as  well  as  thirty  who  had  specific  treatment — and  there  was 
no  secondary  eruption  in  any  of  them  at  the  end  of  seventy 
days.  M.  Bodelio  might  well  say,  "ce  serait  a  faire  doubter 
de  la  nature  syphilitique  de  cette  deplorable  vaccination." 
The  child  from  whom  the  lymph  was  taken  was  ascertained 
to  be  quite  free  from  syphilis,  and  its  parents;  so  also  the 
child  from  which  it  had  been  vaccinated  and  its  parents, 
which  is  as  far  back  as  the  lymph  could  be  traced]  ;  (19)  case 
of  some  children  having  syphilis,  ascribed  to  vaccination  from 
a  child  acknowledged  to  be  perfectly  healthy  at  the  time  of 
vaccination,  and  before  and  long  after,  and  never  manifesting 
at  any  time  to  the  period  when  inquiry  was  made  a  single 
symptom  of  syphilis;  (20)  a  similar  case. 


364  HANDBOOK  OF   VACCINATION. 

three  or  four  weeks  {i.e.  the  ordinary  period  of  the 
incubation  of  syphilis)  ulcerations  of  a  syphilitic  char- 
acter began  at  the  points  of  inoculation  in  nineteen  out 
of  the  twenty-four  persons  operated  on,  and  these  were 
followed  in  due  course  by  constitutional  symptoms. 
Here  was  syphilis,  but  no  vaccination;  what  could 
have  been  the  cause  of  it?  The  vaccinator  who  was 
inculpated  asserted  that  the  operations  were  all  done 
with  lymph  taken  from  one  child,  who  was  1  fort  et 
sain,"  and  who,  having  been  vaccinated  on  the  4th  of 
the  month,  had  regular  vaccinia.  We  shall  see  imme- 
diately how  far  this  statement  was  borne  out:  but  it 
must  first  be  noted — and  is  an  illustration  of  the  want 
of  precision  generally  attending  these  accounts — that 
we  are  nowhere  distinctly  told  whether  the  so-called 
vaccinations,  or  any,  or  which  of  them,  were  done  direct 
from  the  child,  or  whether  the  stuff  taken  from  it  might 
have  not  been  collected  on  glasses,  points,  or  tubes. 
For  all  that  appears  to  the  contrary,  there  was  at  least 
the  possibility  of  a  mistake  (such  as  has  happened  many 
times  with  regard  to  the  matter  of  other  inoculable 
diseases),*  of  taking  lancets,  or  glasses,  or  tubes, 
charged  with  one  kind  of  inoculable  matter  instead  of 
another. .  But,  assuming  that  the  matter  used  came 
from  the  source  indicated,  what  was  the  state  of  this 
source?  Though  it  was  said  to  be  from  an  infant 
"fort  et  sain,"  and  that  this  was  " surabondamment 


*  In  1854  there  was  an  outbreak  of  small-pox  in  a  place  in 
France  from  the  unintentional  use  of  variolous,  instead  of 
vaccine,  matter  for  inoculation.  There  had  been  a  similar 
occurrence  about  the  same  time  in  England.  Such  mistakes, 
unfortunately,  have  on  several  occasions  been  known. 


OBJECTIONS  TO    VACCINATION.  305 

demontre  par  plusiers  temoins,"*  a  different  account 
was  given  by  other  witnesses ;  and  a  doctor  who  saw 
the  child  on  the  21st  of  February,  a  week  after  the 
lymph  was  taken  off  it,  when  of  course  no  suspicion  of 
anything  wrong  had  yet  arisen,  testified  to  the  existence 
of  some  erythematous  eruption,  which  was  said  to  be 
like  syphilitic  roseola,  and  it  died  on  the  24th,  three 
days  after  his  visit,  of  hydrocephalus.  But,  more  im- 
portantly, what  was  the  state  of  its  arm  ?  It  turned 
out  that,  according  to  an  eye-witness,  there  was  on  the 
eighth  day  of  the  child's  vaccination  not  a  vestige  of 
vesicles,  "aucune  trace  de  boutons,"  and  yet  two  days 
later,  the  account  tells  us,  several  vaccinations  were 

*  I  need  scarcely  say  that  such  evidence  as  one  can  get  in 
inquiries  of  this  kind  is  almost  always  tinged  with  great  pre- 
judice, and  requires  to  be  received  with  corresponding  cau- 
tion :  nor  need  I  point  out  that  evidence  may  be  none  the  less 
worthless  because  it  is  given  without  any  intention  of  de- 
ceiving. The  Veterinaire's  own  testimony,  however,  with 
regard  to  the  health  of  this  child  was  just  the  kind  of  testi- 
mony that  proves  too  much.  Before  he  could  think  of  select- 
ing it  as  a  source  of  lymph,  he  made,  we  are  told,  special 
inquiries  about  its  own  health  and  that  of  its  parents:  and 
having  got  a  very  good  account  of  the  latter,  he  took  the  pre- 
caution to  strip  the  child,  "tout  nu,  pour  pouvoir  decouvrir 
la  moindre  egratignure  sur  son  corps."  Nor  was  it  sufficient 
to  do  this  once :  at  the  moment  of  collecting  the  lymph  from 
him,  on  the  13th  of  February,  he  renewed  his  scrutiny,  "afin, 
dit-il,  de  rechercher  si  l'insertion  du  virus-vaccin  chez  cet 
enfant  n'aurait  pas  favorise"  devolution  de  quelque  exantheme 
cache."  Did  anybody  ever  hear  of  such  steps  being  taken 
before  taking  lymph  from  an  apparently  healthy  child  who 
had  genuine  vaccine  vesicles?  Is  there  any  person  of  com- 
mon sense  who  will  believe  that  he  really  did  all  this,  and  did 
not  make  up  the  story  afterward  ? 


366  IIANDBOOK  OF   VACCINATION. 

performed  from  it,  and  lymph  continued  to  be  extracted 
from  it  for  two  days  more!  Is  it  really  meant  that 
between  the  eighth  and  the  tenth  days  vesicles  ap- 
peared, the  products  of  which  communicated  syphilis 
but  no  vaccinia,  but  which  were  yet  genuine  vaccine 
vesicles?  The  supposition  is  too  absurd.  But  the 
case  is  further  instructive  in  my  opinion,  because,  being 
one  which  underwent  a  tolerably  early  investigation, 
the  statements  about  the  child's  health,  and  its  regular 
vaccinia,  could  be  examined  with  some  degree  of  hope 
of  getting  at  the  truth.  If  four  or  five  months _had 
passed,  or  if,  as  in  some  of  the  alleged  cases,  a  much 
longer  time  had  elapsed  before  any  inquiry  had  been 
set  afoot,  how  difficult,  or  how  impossible,  it  might 
have  been  to  correct  the  positive  averments  of  a 
healthy  child  and  a  regular  vaccination! 

In  Hiibner's  case — a  case  also  of  malpractice — there 
could  be  no  doubt  of  some  children  having  been  syphi- 
lized,  but  no  investigation  of  the  circumstances  was 
made  till  eight  months  afterward,  and  the  account  of 
the  so-called  vaccinations  (in  most  of  which  it  is  quite 
certain  and  admitted  there  had  been  no  proper  vaccine 
eifect)  was  only  what  could  be  got  from  the  state- 
ments and  recollections,  at  that  interval  of  time,  of  the 
mothers. 

The  case  of  M.  Trousseau  is  of  a  different  kind,  but 
assuredly  very  instructive.  Its  chief  strength,  in  my 
opinion,  consists  in  the  fact  that  it  satisfied  that  very 
able  and  distinguished  physician.  The  circumstances 
were  these.  A  young  woman  was  under  treatment  in 
the  wards  of  the  Hotel-Dieu,  for  a  uterine  affection  ap- 
parently of  a  non-specific  character,  at  a  time  when 
there  were  some  small-pox  cases  in  the  hospital,  and 


OBJECTIONS   TO    VACCINATION.  367 

wished  to  be  revaccinated.  This  was  done  by  three 
punctures  on  each  arm,  from  a  child,  healthy  at  the 
time,  and  which,  for  anything  that  was  ever  known, 
never  exhibited  any  taint.  Four  children  who  were 
vaccinated  with  its  lymph,  at  the  same  time  with  this 
young  woman,  went  through  vaccinia  in  the  regular 
way,  and  never  had  any  subsequent  syphilitic  affection. 
On  the  young  woman's  arm  slight  papules  only  arose, 
and  the  revaccination  was  looked  upon  as  having  failed. 
She  remained  in  the  hospital  a  month  after  the  vac- 
cination, fully  the  time  necessary  for  the  syphilis,  if 
there  had  been  any  imparted  by  the  vaccination,  to 
have  incubated,  and  she  went  out  without  anything  the 
matter  on  her  arms.  At  the  end  of  another  month  she 
attended  at  the  hospital  for  treatment  of  her  uterine 
complaint,  and  then  showed  two  sores  on  one  of  her 
arms,  the  character  of  which  was  not  at  first  recog- 
nized, but  which  turned  out  to  be  undoubtedly  syphi- 
litic. It  was  not  known  at  the  time,  but  was  afterward 
ascertained,  that  she  was  a  young  woman  of  very  loose 
character.  Now,  assuredly  no  one  who  knows  in  what 
extraordinary  situations  chancres  have  been  met  with, 
such  as  the  cheek,  the  corner  of  the  eye,  in  every  sort 
of  situation  in  which  there  could  not  be  any,  and  never 
was  any,  suspicion  of  vaccination,  can  say  that  this 
was  a  case  entirely  free  from  fallacy  as  to  the  source  of 
the  syphilis :  especially  when  we  consider  that,  in  the 
first  place,  there  was  utter  absence  of  proof  that  the 
child  from  whom  the  lymph  was  taken  ever  had 
syphilis,  and  every  presumption  (from  the  children 
vaccinated  from  it  at  the  same  time  with  this  young 
woman  having  assuredly  never  been  syphilized)  that 
it  had  not ;  and  that,  in  the  second  place,  the  period  of 


368  HANDBOOK  OF   VACCINATION. 

syphilitic  incubation  in  this  case,  if  the  inoculation 
really  "dated  from  the  time  of  the  vaccination  being 
done,  was  of  quite  unusual  length.  But,  supposing 
that  the  effects  were  fairly  traceable  to  the  operation, 
which,  I  would  ask,  in  the  name  of  common  sense,  is 
the  more  probable — that  lymph  which  had  vaccinated, 
without  syphilizing,  four  subjects,  should  syphilize, 
without  vaccinating,  a  fifth,  or  that  in  an  operation  of 
this  kind  done  in  the  wards  of  a  hospital  there  might 
have  been  some  accidental  change  of  instrument,  and 
that  syphilitic  matter,  mixed  or  unmixed,  may  have 
thus  found  its  way  into  the  system  ?  Though  the 
woman  had  expressed  a  wish  to  be  vaccinated,  it  ap- 
pears she  made  a  great  deal  of  difficulty  about  it  when 
it  came  to  the  point,  and  it  was  in  fact  not  done  with- 
out much  urging, — a  small  circumstance,  no  doubt,  and 
yet  one  which  may  not  be  wholly  immaterial,  for  it 
shows  that  all  did  not  pass  in  the  easy  arm-to-arm  way 
of  an  ordinary  series  of  vaccinations.* 

The  occurrences  at  Rivalta,  to  which  so  much  inter- 
est has  attached,  were  of  a  different  kind.  In  1861, 
there  occurred  in  this  village  a  very  remarkable  syphi- 
litic endemic.  Three  similar  endemics  are  said  to  have 
been  noticed  in  different  places  before,  in  1814,  1821, 
and  1841;  and  if  we  include  an  account  given  (though 
not  till  some  years  after  the  occurrence  took  place)  by 
a  Dr.  Marone,  a  fourth  in  1856.  It  is  certainly  very 
singular  that  all  these  endemics  should  have  occurred 
in  Italy ;  and  none  resembling  them  met  with  else- 

*  It  need  scarcely  be  said  that  the  unintentional  inocula- 
tion of  animal  poisons  through  foul  lancets  has  been  known 
to  occur  on  various  occasions,  when  neither  syphilis  nor  vac- 
cination was  in  question. 


OBJECTIONS  TO    VACCINATION.  369 

where.  Whatever  their  origin,  the  facts  are  of  the 
deepest  interest — a  number  of  children  affected  at  one 
time  with  syphilis,  these  infecting  their  nurses  and 
mothers,  the  mothers  infecting  their  husbands,  the 
children  infecting  one  another  by  the  act  of  kissing  or 
by  the  spoons  used  in  feeding,  and  whole  families  in- 
fecting one  another  by  merely  being  huddled  together 
in  confined  and  crowded  dwellings.  For  it  must  not 
be  supposed  that  only  persons  who  were  at  the  time 
the  subjects  of  vaccination  were  the  sufferers.  Various 
endemics  of  this  kind,  quite  as  singular  and  quite  as 
inexplicable,  have  occurred  under  circumstances  en- 
tirely unconnected  with  vaccination,  and  indeed  before 
vaccination  was  known  or  heard  of.  Passing  by  the 
very  interesting  accounts  of  the  spread  of  sibbens  and 
other  syphiloid  diseases  which  will  be  found  on  record, 
I  refer  particularly  to  outbreaks  of  undoubted  syphilis, 
attacking  large  numbers  of  people  at  a  time,  which  are 
related  by  various  writers,  and  which  Astruc  has  col- 
lected together.  Anything  more  puzzling  than  the 
origin  of  these  cases  it  is  difficult  to  conceive.  By 
some  they  were  attributed  to  the  water  in  which  peo- 
ple bathed :  by  others,  to  the  use  of  the  same  cupping 
instruments  (cupping  being  in  those  days  a  sort  of 
fashionable  process).*  In  the  five  endemics  specified 
at  the  beginning  of  this  paragraph  a  vaccinal  origin 
was  alleged :  and  this  was  made  in  the  Rivalta  case 
the  subject  of  careful  inquiry  by  a  scientific  commis- 

*  Astruc  very  sensibly  remarks  that  he  does  not  wonder 
that  suspicion  should  have  fallen  on  the  cupping  instruments, 
but  that  he  does  wonder  how  the  momentary  contact  of  the 
blades  should  have  infused  the  disease  in  the  manner  sug- 
gested. (Dc  Morbis  Venereis.) 
32 


370  HANDBOOK  OF   VACCINATION. 

sion.  Unfortunately,  however,  the  inquiry  did  not 
take  place  till  four  months  after  the  outbreak ;  and  as 
in  no  single  case  of  the  children  said  to  have  been 
syphilized  by  vaccination  had  any  application  been 
made  to  a  medical  man  on  account  of  the  condition  of 
the  arm,  facts  and  dates  on  the  exactitude  of  which 
everything  depends  had  to  be  got  as  they  could  at  such 
distance  of  time  from  the  testimony  of  the  villagers,  for 
the  most  part  ignorant  and  prejudiced.  Under  these 
circumstances,  it  is  not  surprising  that  different  con- 
clusions were  arrived  at :  and  though  Dr.  Pacchiotti 
and  the  other  commissioners,  after  a  most  careful  and 
painstaking  inquiry,  reported  themselves  satisfied  of 
the  vaccinal  origin  of  the  disease,  Sperino,  who  also 
went  to  Rivalta  and  there  investigated  the  circum- 
stances, and  treated  some  of  the  cases  afterward  at 
Turin,  was  equally  satisfied  that  their  origin  was  inde- 
pendent of  the  vaccination.  The  story,  as  regards  the 
vaccinal  origin,  is  this : 

A  child  (Chiabrera)  apparently  in  good  health,  but 
really  incubating  syphilis,  was  vaccinated  with  some 
lymph  obtained  in  a  tube ;  this  child's  arm  was  used 
on  the  tenth  day  for  the  vaccination  of  forty-six  chil- 
dren, and  one  of  these  forty-six  children,  named  Man- 
zone,  again  on  the  tenth  day,  furnished  lymph  for 
vaccinating  seventeen  children;  of  these  sixty -three 
children,  forty-six  had,  within  two  months,  a  disease 
considered  by  the  commission  to  have  been  syphilis, — 
the  syphilitic  symptoms  having  manifested  themselves 
in  some  cases  within  ten  days,  and  as  a  mean,  at  twenty 
days  from  the  vaccination.  Now,  in  explanation  of 
these  events,  can  we  admit  that  the  matter  taken  from 
Chiabrera's  arm  contained  the  contagion  of  the  consti- 


OBJECTIONS   TO    VACCINATION.  371 

tutional  syphilis,  which  at  these  intervals  of  time  the 
children  manifested?  Not,  assuredly,  unless  we  are 
prepared  to  give  up  all  we  have  been  taught  as  to  the 
incubative  period  of  constitutional  syphilis.  For  it 
would  have  required  from  three  to  five  weeks  for  that 
disease  to  manifest  its  primary  symptoms.*  But  if 
this  teaching  has  been  erroneous,  and  true  constitu- 
tional syphilis  can  produce  its  primary  symptoms 
within  ten  days,  then  indeed  we  can  understand  how, 
if  syphilitic  matter  was  mixed  with  the  lymph,  either 
in  the  original  tube,  or  through  the  lancet  employed  in 
Chiabrera's  vaccination,  an  irregular  vesicle  might  re- 
sult, such  as  that  stated  in  Sperino's  experiment  with 
soft  chancre,  which  Baumes  and  Viennirs  held  to  con- 
tain the  two  viruses  mixed.  It  must  be  remembered 
that  we  have  no  reliable  account  whatever  of  what  was 
the  sort  of  vesicle  or  result  on  Chiabrera's  arm,  from 
which  the  so-called  vaccinations  were  done.f  From 
such  a  result  as  Sperino's  experiment  affords  (p.  348), 
a  careless  man  might,  a  careful  man  would  not,  take 
what  he  called  lymph ;  and  I  have  very  little  faith  in 
the  proceedings  of  any  one  who  evidently  habitually 
used  tenth-day  cases.    We  might  not  really,  then  (that 

*  Lee  gives  the  period  of  incubation  at  from  three  to  seven 
weeks.  Kollett  gives  a  mean  of  twenty-six  days,  and  out  of 
a  large  number  of  cases  there  was  only  one  case  in  which  it 
was  under  fifteen  days.  In  four  cases  in  which  the  inocula- 
tion was  by  blood  the  minimum  was  twenty-five  days  and 
the  maximum  thirty-five.  (Rollet,  Traite  des  Maladies  V6n6- 
ricnnes.) 

f  There  is  only  the  mother's  account  that  it  was  regular ; 
but  I  have  already  pointed  out  into  what  errors  parents  often 
fall  on  this  subject. 


372  HANDBOOK  OF    VACCINATION. 

is,  supposing  the  incubation  difficulty  got  over,  which 
it  must  be,  or  else  the  Rivalta  cases  as  connected  with 
vaccination  fall  of  themselves),  have  any  difficulty  in 
accounting  for  the  propagation  of  syphilis,  for  hard 
and  soft  chancre  would  fall  in  the  same  category.  But 
we  should  have  more  hesitation  as  to  whether  vaccinia 
also  might  be  communicated  at  the  same  time  ;  and,  in 
fact,  in  what  degree  the  Rivalta  children,  who  were 
syphilized,  were  also  vaccinated,  it  is  impossible  to  say. 
I  can  quite  conceive  that  if  the  vesicle  on  Chiabrera's 
or  Manzone's  arm  was  at  all  like  that  produced  in 
Sperino's  experiment,  some  spurious  vaccine  result 
might  follow  in  some  of  those  vaccinated  from  them. 
There  is  certainly  no  satisfactory  evidence  of  any  of 
the  children  ever  having  had  regular  vaccinia.  When 
the  arms  were  first  seen  (by  Dr.  Katt),  or  when  they 
were  seen  by  the  commission  of  inquiry,  they  pre- 
sented either  so  many  syphilitic  sores,  or  else  cicatrices, 
which,  according  to  the  description  given,  had  no  vac- 
cine character  about  them ;  and  the  fact  that  the  revac- 
cination  of  five  of  the  children  was  afterward  without 
effect  (a  revaccination  which  it  is  not  stated  was  re- 
peated) is  far  from  being  conclusive.* 

None  of  the  alleged  cases,  then,  have  established, 
in  my  opinion,  that  syphilis  has  ever  been  imparted  in 
the  due  and  proper  performance  of  vaccination,  i.e. 
with  the  unmixed  lymph  of  a  genuine  vaccine  vesicle. 
They  are  not  even,  in  my  opinion,  at  all  conclusive  as 
to  this  having  been  done  by  the  inoculation,  along  with 

*  It  would  be  singular,  no  doubt,  provided  there  had  been 
no  previous  vaccine  effect,  but  not  the  least  singular  if  there 
had  been  a  spurious  effect. 


OBJECTIONS   TO    VACCINATION.  373 

lymph,  of  a  small  quantity  of  syphilitic  blood — al- 
though I  hope  that  it  is  unnecessary  for  me  to  say  that 
this  is  not  a  matter  in  which  the  slightest  posssibility 
of  risk  should  be  allowed,  and  that  a  practitioner  would 
be  indeed  highly  culpable  who  should  vaccinate  with 
anything  but  pure  and  unmixed  lymph,  or  who,  in  fact, 
should  knowingly  vaccinate  from  a  syphilitic  child  at 
all.  But  whether  from  admixture  of  blood,  or  from 
admixture  of  the  inoculable  secretions  or  products  of 
syphilis,  as  through  foul  lancets  or  in  any  other  way, 
the  real  risks  are,  I  believe,  entirely  risks  of  careless- 
ness— risks  which,  with  due  regard  to  the  rules  which 
have  been  laid  down  for  the  proper  performance  of 
vaccination,  could  not  occur.* 


*  The  performance  of  vaccination  direct  from  animals,  in 
whom  the  cow-pox  has  been  artificially  maintained,  as  already 
described  (§  12,  a,  p.  25),  has  been  suggested  as  a  way  that 
would  effectually  obviate  any  possibility  of  invaccinating 
syphilis.  And,  following  a  plan  which  was  previously  in  use 
at  Naples,  animal  vaccinations,  as  they  are  called,  have  been 
practiced  to  a  limited  extent  of  late  in  Paris  and  elsewhere. 
But  the  difficulties  in  applying  such  a  plan  to  the  vaccination 
of  the  general  population  are,  I  apprehend,  quite  insuperable ; 
even  on  the  very  limited  scale  on  which  the  practice  has  been 
attempted  at  the  Academie  (from  seven  to  eight  hundred  vac- 
cinations a  year),  the  resources  in  animals  did  not  allow  of  the 
vaccinations  being  done  under  the  conditions  believed  to  be 
most  favorable  for  success  in  more  than  60  per  cent,  of  the 
cases  ;  and  the  rest  were  done  under  circumstances  of  great 
disadvantage.  But  an  objection,  in  my  opinion,  even  to  its 
limited  application,  is  that  it  tends  to  weaken  our  defenses 
against  small-pox.  Small-pox  is  yet  so  formidable  an  enemy 
that  no  risk  of  this  must  be  run,  out  of  fear  of  small,  and 


3T4  HANDBOOK  OF   VACCINATION. 

(g)  The  Practical  and  Common-sense  View  of  the 
Question. — Suppose,  however,  that  there  existed  risks 
of  vaccino-syphilitic  inoculation,  greater  than  I  can  al- 
low to  have  been  shown,  and  that  the  occurrence  is 
one  that,  under  some  unknown  conditions,  might  take 
place  in  a  properly-performed  and  careful  vaccination ; 
what,  after  all,  looking  at  the  matter  in  a  plain,  practi- 
cal, common-sense  way,  do  these  risks  amount  to? 
Suppose  we  assume  that  in  all  the  cases  that  have 
been  advanced,  except  those  in  which,  on  the  very  face 

almost,  if  not  quite,  hypothetical  dangers.  Our  great  defense 
against  it  consists  in  making  vaccination  successful,  and  fully 
successful;  in  taking  care  that  when  parents  bring  their  chil- 
dren to  be  vaccinated,  these  shall  be  infected  at  once  and  in- 
fected completely ;  and  this  is  just  what  animal  vaccination 
does  not  do.  (See  ante,  p.  Ill,  note.)  There  is  no  one  in  Eng- 
land whose  opinion  on  this  subject  will  be  received  with  so 
much  respect  as  Mr.  Ceely's,  because  there  is  no  one  who  has 
nearly  the  knowledge  that  he  possesses  of  the  disease  in  the 
cow  and  of  its  transplantation  to  the  human  species.  He  looks 
upon  this  proceeding  as  not  only  open  to  the  objections  of  im- 
practicability, as  applied  to  the  general  population,  and  of 
unsuccess  ;  but  he  says  also  that,  so  far  from  being  likely  to  pro- 
duce fewer  ailments  and  cutaneous  eruptions  in  the  predis- 
posed, he  knows  from  his  experience  that  it  would,  as  being 
more  irritating,  produce  more.  He  regards  it  as  uncalled  for, 
either  for  regenerating  lymph  or  for  preventing  syphilis. 
With  regard  to  the  latter,  he  says:  "I  cannot  but  think  our 
continental  brethren  are  very  careless  vaccinators,  and  that 
syphilis  must  be  very  much  more  prevalent  among  their  in- 
fantile population  than  with  us.  It  is  remarkable  that  so 
many  cases  of  vaccino-syphilitic  inoculation  are  reported  on 
the  continent  while  we  hear  of  no  such  thing  here.  I  cannot 
persuade  myself  that  such  inoculations  are  unavoidable."  (See 
British  Med.  Journ.,  Jan.  7,  1865.) 


OBJECTIONS  TO    VACCINATION.  375 

of  the  story,  there  was  manifest  malperformance,  the 
vaccination  had  been  properly  done,  what  proportion 
do  these  bear  to  the  millions  upon  millions  of  vaccina- 
tions that  have  been  performed?  If  men  who  have 
been  all  their  lives  professional  vaccinators,  as  Marson, 
or  Leese,  or  Tomkins;  if  men  whose  professional  lives 
have  been  spent  in  the  midst  of  syphilis,  as  Lee,  or 
Acton,  or  Langston  Parker,  have  met  with  no  cases  in 
which  syphilis  originated  in  this  way,  the  conditions 
under  which  the  occurrence  can  take  place  must  be 
indeed  of  rare  exceptionality.  During  the  eight  years 
in  which  there  has  been  systematic  inspection  of  public 
vaccination  in  England,  some  millions  of  vaccinations 
have  been  performed;  but  the  inspectors  have  no 
knowledge  of  any  such  accident  having  occurred  in 
any  one  instance. 

"Either,"  as  Simon  has  well  put  it,  "  it  is  the  case 
that — even  with  reprehensible  carelessness  as  to  the 
source  of  lymph,  vaccination  (so  long  as  in  any  sense 
of  the  word  it  is  vaccination)  cannot  be  the  means  of 
communicating  any  second  infection ;  or  else  it  is  the 
case  that  in  the  world  of  vaccinators,  care  is  almost 
universally  taken  to  exclude  the  possibility  of  danger."* 
The  fifty-six  thousand  lives  which  at  the  least  are  now, 
on  an  average,  saved  annually  from  small-pox  in  Eng- 
land alone,  are  not  gained  without  here  and  there  a 
child  getting  erysipelas  from  its  vaccination,  and  even 
in  cases,  of  excessive  rarity,  dying  of  it ;  but  what 
reasonable  man  ever  hesitates  on  account  of  this  risk 
— "risque,"  as  Trousseau  says,  "bien  plus  grands  que 
les  chances  a  peu  pres  nulles  de  la  syphilis" — to  have 

*  Simon,  Preface,  etc.  (op.cit.),  p.  lxxxi. 


376  HANDBOOK  OF   VACCINATION. 

his  child  vaccinated  ?  The  danger,  if  indeed  there  be 
any  at  all,  of  communicating  through  vaccine  lymph, 
as  in  an  ordinary  well-performed  vaccination,  any- 
other  infection  than  its  own,  must  be  so  infinitesimally 
small,  that  for  all  practical  purposes  we  may  regard  it 
as  non-existent. 


INDEX. 


Abrasion,  forms  of  vaccination  by,  130; 
the  most  successful  mode  when  dry  lymph 
is  used,  134. 

Academic  de  Medecine,  lymph  in  use  at, 
in  1836,  203 ;  vaccination,  how  performed 
at,  206  n.,  352;  discussions  on  vaccinal 
syphilis,  356;  reports,  referred  to peusim. 

Accelerated  vaccination,  89. 

Age  at  which  vaccination  should  be  per- 
formed, 117;  at  which  revaccination 
should  be  performed,  301. 

Age,  influence  of,  on  the  protective  power 
of  vaccination,  250. 

Alfort,  outbreak  of  the  horse-pox  at,  38. 

Alison,  Professor,  his  observations  on  the 
protective  power  of  vaccination,  234;  on 
its  value  in  preventing  the  scrofula  con- 
sequent on  small-pox,  332. 

Animal  vaccination,  109,  373  n. 

Areola,  its  color  in  the  cow  influenced  by 
the  hue  and  texture  of  the  skin,  13. 

Areola  in  the  human  subject,  81 ;  import- 
ance of  its  regular  development,  81,  86. 

Arm-to-arra  vaccination,  125;  its  vast 
superiority,  140,  180,  also  111  n.;  con- 
trasted with  use  of  stored  lymph,  170, 
191. 

Army,  cases  and  deaths  from  small-pox 
in  the,  273,  284;  vaccination  in  the, 271; 
results  of  revaccination  in  the,  311. 

Arnott,  Dr.,  his  cases  of  strong  family  dis- 
position to  small-pox,  256. 

Arrangements  for  vaccination,  140. 

Artilicial  production  of  cow-pox  in  the 
cow,  25. 

Artificial  production  of  the  horse-pox,  40. 

Aylesbury,  cow-pox  in  the  Yale  of,  24. 

Badcock's  successful  variolations  of  cows, 
60;  numerous  vaccinations  with  his 
variola-vaccine  lymph,  66. 

Baron,  Dr.,  on  liability  of  cattle  to  malig- 
nant form  of  cow-pox,  74. 

Baron's  Life  of  Jenner,  referred  to  ptmaim. 

Bath  Union,  deaths  from  small-pox  in  the, 
2112  n. 

Bavarian  army,  compulsory  revaccination 
in  the,  304 ;    its  results,  304. 

Bengal  army,  statistics  of  small-pox  in, 
279. 

Berlin,  decline  of  small-pox  in,  since  the 
introduction  of  vaccination,  280. 

Black-pock, 19. 

Blister-pock,  19. 

Blood,  question  of  inoculation  of  syphilis 
by  the,  353. 

Blot's  account  of  vaccination  as  practiced 
at  the  Academic,  206  n. 


Bohemia,  decline  of  small-pox  in,  sinco 
the  introduction  of  vaccination,  280. 

Bombay  army,  statistics  of  small-pox  in, 
279. 

Bouley's  experiments,  40,  72. 

Bridgewater  Level,  cow-pox  in  the  dairies 
of,  24. 

Brighton  Union,  deaths  from  small-pox#n 
the,  292  n. 

Brown's  inoculations  with  lymph  from  a 
cow  in  India,  78. 

Bryce's  proposal  of  a  special  class  of  "  vac- 
cinators," 186. 

Bryce's  test,  98. 

Buchanan  and  Seaton's  observations  on 
vaccination  in  London,  247;  on  the 
importance  of  having  special  "vaccina- 
tors," 187. 

Burton-on-Trent  Union,  deaths  from  small 
pox  in  the,  292  n. 

Bussunt,  disease  of,  in  cattle  in  India,  75. 


Camel,  pock  analogous  to  cow-pox  in  the, 
54. 

Canterbury  Union,  deaths  from  small-pox 
in  the,  292  n. 

Cardiff,  deaths  from  small-pox  in,  319. 

Cardiff  Union,  deaths  from  small-pox  in 
the,  292  a. 

Care  in  vaccinating,  Marson  on  importance 
of,  196. 

Carelessness,  dangers  of,  346. 

Carmarthen  Union,  deaths  from  small-pox 
in,  319. 

Carnarvon,  deaths  from  small-pox  in,  320. 

Cattle,  inoculation  of,  with  small-pox,  57 ; 
infection  of,  by  variolous  effluvia,  58,  88 : 
not  shown  to  be  subject  to  any  other 
variolous  affection  than  cow-pox,  74. 

Ceely,  Robert,  his  description  of  cow-pox, 
9;  his  enumeration  of  different  kinds  of 
spurious  pock,  19  ;  his  drawings  of 
casual  blister-pox  on  the  hands  of  milk- 
ers, 20 ;  his  inoculations  of  cattle  with 
various  kinds  of  vaccine  lymph,  25,  30; 
his  experiments  with  sheep-pox  lymph, 
47;  his  success  in  variolating  cows,  60; 
his  account  of  the  phenomena  induced, 
63;  his  case  of  infection  of  cows  by 
variolous  effluvia.  62;  his  account  of 
the  effects  of  variola-vaccine  lymph  on 
the  human  subject,  107 :  his  experiments 
and  observations  on  different  lymphs, 
210;  his  observations  on  animal  vaccina- 
tion, 374  n.;  his  essays  referred  to pnimini. 

Ceylon,  epidemics  of  small-pox  in,  277. 

Chauveau's  experiments  on  horso-pox,  41 ; 


33 


(37*7) 


378 


INDEX. 


his  experiments  in  inoculating  cattle 
with  variolous  matter,  66. 

Chiabera,  alleged  case  of  vaccinal  syphi- 
lis, 370. 

Childhood,  circumstances  under  which  re- 
vaccination  is  called  for  in,  301. 

Children  specially  the  victims  of  natural 
small-pox,  212,  286;  post-vaccinal  small- 
pox of,  is  generally  a  very  trivial  affec- 
tion, 250. 

China,  small-pox  in  British  army  and 
navy  in,  2">7. 

Christ's  Hospital,  proofs  of  protective 
power  of  vaccination  from,  275. 

Cicatrices  left  after  the  falling  of  the  cow- 
pox  crusts  in  the  cow,  15. 

Cicatrix,  vaccine,  in  the  human  subject, 
characters  of  the,  82 ;  importance  of 
the,  as  a  test  of  the  quality  and  protect- 
ive value  of  the  vaccination,  241. 

Claveau,  le,  the  sheep-pox  of  the  French, 
44. 

Clavelization,  45. 

Climate,  effects  of,  on  the  course  of  vaccin- 
ation, 94;  effects  of,  on  the  keeping  of 
lymph,  95,  276;  change  of,  its  influence 
on  the  liability  to  small-pox,  257 ;  pro- 
tective power  of  vaccination  against 
small-pox  is  seen  in  all,  275. 

Coleman's  experiments  with  lymph  from 
the  horse,  35. 

Constitutional  symptoms  of  vaccinia,  81. 

Copenhagen,  decline  of  small-pox  since 
the  introduction  of  vaccination  in,  280. 

Cow,  vaccinia  or  cow-pox  in  the,  9;  the 
cow-pox  not  considered  by  Jenner  as  a 
natural  disease  in  the,  21 ;  artificial  pro- 
duction of  cow-pox  in  the,  40;  change 
which  the  variolous  virus  undergoes  in 
passing  through  the,  65;  vaccination 
from  the  natural  orcasual  disease  in  the, 
136 ;  how  to  establish  a  stock  of  lymph 
from  the,  139;  recurrence  to  the,  for 
lymph  unnecessary,  199.  (See  Cow- 
pox.) 

Cow-lymph,  inoculation  of  cows  with,  25; 
inoculation  of  horses  with,  41 ;  phenom- 
ena of  vaccinating  with  primary,  101 ; 
with  secondary,  109;  Ceeley's  observa- 
tions as  to  collecting  it,  137;  it  should 
be  taken  before  acuminatum  of  the  vesi- 
cle, 138. 

Cow-pox,  the  "variolas  vaccinae"  of  Dr. 
Jenner,  9 :  natural  history  of,  9 ;  a  spe- 
cific eruptive  disease,  9;  yonng  cows  and 
milch  heifers  more  subject  to  it  than 
older  cows,  10 ;  not  peculiar  to  the  milch 
cow,  10  n.;  course  of  local  phenomena  at- 
tending it,  11 ;  earliest  symptoms  of  the 
disease,  11 ;  number,  size,  etc.  of  the 
vesicles  in  different  animals,  12 ;  amount 
of  eruption,  and  consequent  severity  of 
the  disease,  depend  much  on  the  state  of 
the  teats,  etc.,  12  n.;  formation,  color,  etc. 
of  the  areola,  13;  acurai  nation  of  the 
vesicle,  13 :  cicatrices  left  after  the  fall- 
ing of  the  crusts,  15 ;  effects  of  handling 
on  the  local  affection,  15 ;  progress  and 
character  of  the  disease,  16:  duration  of 
the  various  stages  of  the  disease,  16; 
structure  of  the  vesicle,  17;  constitu- 
tional symptoms,  18;  spurions  pocks, 
18;  diagnosis  of  the  disease,  19;  casual 


blister-pox  on  the  hands  of  milkers, 
20  n.;  supposed  origin  of,  from  "grease," 
21 ;  has  a  common  specific  infection  with 
the  horse-pox,  21 ;  geographical  distri- 
bution of,  22  ;  its  frequent  recurrence  in 
some  localities,  24 ;  artificial  production 
of,  in  the  cow,  25;  by  inoculation  with 
cow-lymph,  26;  by  equination,  28;  by 
retro-vaccination,  30;  relations  of  horse- 
pox  to,  33;  of  some  pocks  in  other  ani- 
mals to,  44,  54  ;  of  human  variola  to,  56 ; 
Dr.  Jenner's  views  on  the  subject,  56; 
cow-pox  produced  in  cows  by  variolous  ef- 
fluvia, 58;  produced  by  successful  vario- 
lation of  cows,  63 ;  cattle  not  shown  to 
be  subject  to  any  other  variolous  affec- 
tion than,  74;  can  only  be  communica- 
ted to  the  human  subject  by  inoculation, 
'80;  course  of,  in  persons  not  previously 
infected  by  it,  80 ;  usual  course,  81 ;  con- 
stitutional symptoms,  81 ;  abnormal 
course,  85;  simple  retardation,  85;  re- 
tardation from  incubation  of  measles, 
scarlatina,  etc.,  86 ;  from  incubation  of 
small-pox,  88 ;  simple  acceleration,  89 ; 
spurious  form,  89 ;  effects  on  its  course 
of  mechanical  interference  with  the  ves- 
icle, 92;  degeneration  of  the  vaccine 
vesicle,  93;  effects  of  climate  on  the 
course  of  vaccination,  94;  supernumer- 
ary vesicles,  96 ;  reinsertion  of  vaccine 
lymph  (Bryce's  test),  98 ;  its  history,  99 ; 
its  analogy  with  some  of  the  phenomena 
of  natural  cow-pox,  101 ;  vaccination 
with  primary  cow-lymph,  101 ;  local  phe- 
nomena and  general  symptoms,  102; 
progress  of  humanization  of  lymph,  104; 
varieties  in  amount  of  constitutional 
disturbance,  104 ;  symptoms,  etc.  of  the 
casual  cow-pox  of  milkers,  106 ;  vaccin- 
ation with  variola-vaccine  lymph,  107 ; 
with  secondary  cow-lymph,  109;  diffi- 
culties attending  the  transplantation  of 
primary  cow-lymph  to  the  human  sub- 
ject, 102,  111  n.;  vaccination  with  retro- 
vaccine  lymph,  112;  phenomena  and 
course  of  revaccination,  113 ;  treatment 
of  revaccination,  114  (see  Vaccina- 
tion) ;  the  natural  cow-pox  still  not  in- 
frequent on  the  dairy-farms  of  the 
Bridgewater  Level  and  the  Vale  of  Glou- 
cester, 24, 209. 

Cows,  attempts  to  ovinate,  51 ;  difficulties 
of  infecting,  with  variolous  virus,  58 ; 
Dr.  Thiele's  success,  59;  Ceely's  suc- 
cess, 60;  Badcock's  success,  60;  phe- 
nomena of  successful  variolation  of, 
63. 

Cross's  observations  on  the  protection  af- 
forded by  vaccination,  262. 

Crusts,  vaccine,  fall  from  the  14th  to  the 
20th  day  in  the  cow,  28 ;  from  the  20th 
to  the  25th  day  in  the  human  subject,  82 ; 
used  for  vaccinating,  174. 

Cutaneous  diseases,  on  the  allegation  that 
they  may  be  invaccinated,  334. 


Death-returns  of  small-pox  in  England, 

analysis  of  the,  286. 
De  Carro,  Dr.,  his  successful  introduction 

of  the  vaccine  lymph  into  India,  176. 
Degeneration  of  lymph,  and  decadence  of 


INDEX. 


379 


Tftccine  power,   allegations  respecting, 

not  supported  by  facts,  2(10,  270,  884. 
Diagnosis  of  true  cow-pox  in  the  cow,  19. 
Disinfection,    measures  of,   indispensable 

to  extinguish  small-pox,  31C>,  SB. 
Districts  for  public  vaccination,  143. 
Dogs,  vaccination  of,  54. 
Dover  Union,  deaths  from  small-pox  in 

the,  292  n. 
Dry-lymph,   how    to    be    used,    131 :    its 

advantages    as    compared    with    tube- 

lymph,  170. 
Dudley  Union,  deaths  from  small-pox  in 

the,  "291. 
Duncan,  the,  infected  by  small-pox  from 

Portsmouth,  292. 

Earle's  cases  of  small-pox  after  inocula- 
ted small-pox,  22.">. 

East  Indies,  small-pox  in  the  army  and 
navy  in  the,  2.">7,  278. 

England,  deaths  from  small-pox  in,  280, 
291. 

Epidemic  influence,  effect  of,  on  the  pro- 
tective power  of  vaccination,  269. 

Epidemics  of  small-pox  in  Ceylon,  277 ;  in 
the  Mauritius,  278 ;  frequency  of  recur- 
rence in  London,  280  n. 

Equination.  vaccine  disease  may  be  in- 
duced in  the  cow  by,  25,  28. 

Erysipelas,  occurrence  of,  after  vaccina- 
tion, 93. 

Estlin's  lymph-stock,  105,  208. 

Europe,  statistics  of  small-pox  in,  showing 
the  power  of  vaccination,  279. 

Kiri/iihi.i,  small-pox  on  board  the.  266. 

Exposure  to  the  small-pox  infection,  fre- 
quency and  extent  of  their  influence  on 
post-vactinal  small-pox  mortality,  261. 

Family  tendency  to  small-pox,  254 
Farr,  Dr.,  on  the  diminution  of  febrile  and 

scrofuious  diseases,  332. 
Febrile  diseases,  diminution  of,  331. 
Fever,  present  death-rate  of,  as  compared 

with  former  rate,  332. 
France,  practice  of  vaccination  in,  349. 

Gardner's  report  of  the  Mauritius  epi- 
demic. 278. 

Geographical  distribution  of  cow-pox,  22. 

Gil  ham's  experiments  w  ith  Estlin's  lymph, 
208. 

Glandular  diseases,  allegation  that  they 
may  be  inraccinated,  334. 

Glasses  used  for  preserving  lymph,  162. 

Gloucester,  cow-pox  in  the  Vale  of,  23, 

Goat  said  to  be  susceptible  of  vaccination, 

55. 
Gotce,  disease  of,  in  cattle  in  India,  75. 
"Grease,"    supposed    origin    of   cow-pox 

from,  21 ;  relations  of  horse-pox  to.  33. 
Grove's  cases  of  post-vaccinal  small-pox, 

255. 
Guardians,  Boards  of,  their  responsibilities 

in  reference  to  small-pox,  327. 

Health,  an  important  consideration  with 
regard  to  performance  of  vaccina  ion, 
li:.. 

Hereditary  tendency  to  small-pox,  I 


Ilering's  observations  on  cow-pox,  22  n., 
23. 

Horse,  subject  to  disease  identical  with 
cow-pox,  36 ;  experiments  in  proof,  36 ; 
inoculations  of,  with  variolous  virus,  42. 

Horse-pox,  its  relations  to  cow-pox,  33; 
and  to  "grease, "33;  various  experiments 
in  producing,  34 ;  direct  inoculation  from 
horses'  heels,  35;  distinguished  by  the 
appropriate  name  of  "variolas  equi- 
na;," 37  ;  outbreaks  of  the  disease  among 
horses  at  Alfort  and  Rieumes,  char- 
acter and  course  of  the  disease.  38 ; 
to  be  distinguished  from  "grease"  on 
the  one  hand,  and  aphtha  epizootica  on 
the  other,  40;  artificial  production  of, 
by  inoculation,  40 ;  by  injection  of  lymph, 
42 ;  Chanveau's  various  experiments  for 
producing,  41 ;  the  pocks  in  other  animals 
which  have  been  considered  analogous 
to,  44 ;  relation  of,  to  human  variola,  56. 

Hughes,  Dr.,  of  Mold,  the  statistics  of 
vaccination  in  his  district,  289  ».;  im- 
munity of  the  district  from  small-pox. 
288. 

Human  subject,  attempts  to  ovinate  the, 
45;  vaccinia  or  cow-pox  in  the,  80. 

Humanization  of  lymph,  difficulties  attend- 
ing the,  102,  111  «.;  effects  of  lymph  in 
progress  of  being  humanized,  104. 

Husband,  Dr.,  his  description  of  capillary 
tubes  and  the  method  of  using  them,  163  ; 
his  table  showing  the  reBnlts  of  lymph 
kept  in  tubes  for  different  periods,  173. 

Imperieuse,  small-pox  on  board  the,  266. 

Incubation  of  measles,  etc.,  its  effects  on 
vaccination,  86. 

Incubation  of  small-pox,  its  effects  on  vac- 
cination, 88. 

India,  experiments  with  lymph  taken  from 
cattle  in,  75;  establishment  of  vaccin- 
ation in,  176;  statistics  of  small-pox, 
279. 

Infantile  vaccination,  the  laws  respecting, 
should  be  administered  with  the  utmost 
strictness  in  large  towns,  280. 

Inoculation  of  small-pox  in  animals,  42, 
55,  57. 

Inoculation  of  small-pox  in  the  human 
subject,  its  introduction,  216;  its  results, 
217. 

Inspection  of  results  after  performance  of 
vaccination,  its  great  importance,  134. 

Insusceptibility  of  vaccination,  196. 

Italy,  practice  of  vaccination  in,  350. 

Jen i-vkk,  Dr.,  his  inquiries  about  the  cow- 
pox,  21,  21;  his  belief  that  the  disease 
originated  in  the  horse,  21,  34;  con- 
founded at  first  the  equine-pox  with 
"grease,"  21,  33;  but  afterward  noted 
their  merely  accidental  connection,  36: 
his  views  on  the  relation  of  these  dis- 
eases to  variola,  56:  his  discovery  of 
vaccination,  219:  his  observations  on 
the  influence  of  herpes  and  other  erup- 
tions on  the  course  of  vaccination,  93, 
116;  his  rule  to  have  the  skin  freo  from 
eruption,  Iwforc  vaccination,  117;  his 
"golden  rule''  about  lymph-taking,  123; 
his  remarks  on  the  arrangements  neces- 
sary for  vaccination,  141 ;  on  the  use  of 


380 


INDEX. 


the  vaccine  crust,  174 ;  on  the  training 
required  bj  vaccinators,  182;  no  believer 
in  the  degeneration  of  lymph,  199;  proofs 
of  the  correctness  of  liis  views  in  this 
respect,  101 ;  his  demonstration  of  the 
protective  power  of  vaccination,  221; 
his  opinion  as  to  the  extent  of  this,  222 ; 
small-pox  itself  does  not  always  prevent 
small-pox,  226;  showed  that  cow-pox 
may  be  taken  again  and  again  by  human 
subjects,  but  that  a  second  taking  did 
not  prove  them  to  be  liable  to  variola, 
312;  his  anticipation  that  vaccination 
would  indirectly  diminish  scrofula,  333 ; 
shown  to  be  correct,  333;  his  proposal 
for  conveying  vaccination  to  India,  176. 
Jenncr.  Sir  Wm.,  cutaneous  and  other  dis- 
eases, ..'it  induced  by  vaccination,  336. 

Kaiu.kht,  of  Prague,  his  observations  on 
the  horse-p>x  in  Bohemia,  37. 

Kendrick,  Dr.,  his  cases  of  post-vaccinal 
small-pox,  255. 

Kite's  cases  of  small-pox.after  inoculated 
small-pox,  226. 

La  Font's  experiments  with  lymph  of 
horse-pox,  35. 

Lafosse,  M.,  description  of  phenomena 
induced  in  cows  by  equination,  29. 

Lee,  Mr.  II..  his  mistaken  announcement 
of  a  case  of  vaccinal  syphilis,  357. 

Leith's  statistics  of  Bombay,  279. 

Lichen,  vaccine,  83. 

Lincoln  General  Dispensary,  facts  from 
its  practice,  showing  the  imperfect  per- 
formance of  vaccination,  195. 

London,  decline  of  small-pox  in,  since  the 
introduction  of  vaccination,  280;  epi- 
demics in,  289  «.;  annual  mortality  from 
small-pox,  280. 

Loy's  experiments  with  lymph  from  the 
horse,  34. 

Lymph,  equine,  used  by  Jenner  and  others 
for  vaccinating,  34;  the  lymph  first  con- 
veyed effectually  to  India  was  equine, 
177 ;  used  for  experiments,  29,  34,  40,  42. 

Lymph,  vaccine,  inoculation  of  cows  with, 
25,  30;  of  horses  with,  41;  injection  of, 
into  the  blood-vessels  of  horses,  42; 
effects  of  insertion  of,  in  different  ani- 
mals, 54 ;  inoculation  of  human  subjects 
with,  80;  fallacies  which  may  arise  in 
trials  of  new  lymph,  if  small-pox  is  pre- 
vailing, 79  n.;  variola-vaccine,  66,  107 ; 
retro-vaccine,  112;  selection  of,  for  vac- 
cinating, 123;  collection  of  it,  124;  vac- 
cinating with  stored  lymph,  125 ;  various 
methods  of  inserting  lymph,  126;  by 
puncture,  126;  by  scarification,  129;  by 
abrasion,  130;  particular  steps  necessary, 
when  it  is  dry-stored,  131 ;  is  any  one 
mode  of  inserting  it  better  than  another, 
13 1 ;  arrangements  for  the  maintenance 
of  supply  of,  140;  selection  of,  necessary 
to  prevent  its  degenerating,  141,200 ;  con- 
tinuous supplies,   depend   on   arrange- 

•  ments  for  public  vaccinations  in  large 
towns,  143;  proper  arrangements  for  sup- 
ply in  large  towns,147;  great  want  of  such 
arrangements  hitherto,  151 ;  arrange- 
ments for  supply  of,  in  small,  urban 
populations,  152 ;  in  still  smaller  towns, 


and  in  rural  districts,  153;  conveyance 
and  storage  of,  158 ;  vaccine  bottle,  159 ; 
poiius,  161 ;  glasses  and  tubes,  162  (see 
Tubes)  ;  the  best  mode  of  storage,  168 ; 
great  uncertainty  attached  to  its  success 
when  long  kept  dry,  172;  length  of 
keeping  does  not  damage  it  when  kept 
in  tubes,  172 ;  Dr.  Husband's  table  of  its 
effects,  when  kept  for  different  periods, 
173 ;  transmission  of,  to  tropical  climates, 
cautions  respecting,  174;  successfully 
introduced  into  India,  176 ;  standard  of, 
when  stored  lymph  is  used,  181 ;  illus- 
trations of  use  of  stored  lymph,  168;  of 
alleged  degeneration  of,  199;  Jenner's 
opinion  on,  199;  Simon's  opinion  on, 
200  n.;  the  vesicles  produced  by  Jenner's 
lymph  have  the  same  character  and 
course  as  he  described,  201 ;  and  leave 
the  same  kind  of  cicatrices,  203 ;  when 
accidentally  degenerated  lymph  should 
be  at  once  changed,  204 ;  particular  kinds 
of,  205;  the  Passy  lymph,  and  other  more 
recent  French  stocks,  205;  Estlin's 
lymph,  208;  Bousquet's  account  of  the 
lymph  of  the  Academie  de  Medecine, 
with  which  the  Passy  lymph  was  com- 
pared, 205;  Ceely's  experiments  with 
different  kinds  of,  210;  primary  lymph- 
stocks  differ  in  their  action,  210. 
Lvinph-stock  set  in  circulation  by  Mr. 
Estlin,  of  Bristol,  208. 

Macpherson's  experiments  in  vaccina- 
tion with  lymph  from  cows,  76. 

Madras  army,  statistics  of  small-pox  in, 
279. 

Marshall's  cases  of  post-vaccinal  small- 
pox, 255 ;  inquiry  into  epidemic  at  Chel- 
sea, 263. 

Marson's  experiments  with  ovine  lymph, 
and  vaccination  of  sheep,  47,  50;  his 
standard  of  successful  vaccination,  180; 
his  statements  of  the  amount  of  bad 
vaccination  in  England,  187 ;  his  obser- 
vations on  the  severity  and  danger  of 
post-vaccinal  small-pox  as  influenced  by 
cicatrices  after  vaccination,  244  ;  his  re- 
port of  the  proportion  of  cases  of  second 
small-pox,  296  n. 

Measles,  effects  of  incubation  of,  on  the 
course  of  vaccination,  86. 

Mechanical  interference,  effects  of,  on  the 
course  of  vaccination,  92. 

Merthvr  Union,  deaths  from  small-pox  in 
the, '292  n. 

Milch  cow  particularly  liable  to  vaccinia, 
10.    (See  Cow-pox.) 

Milkers  apt  to  contract  cow-pox,  and  con- 
vey it  from  animal  to  animal,  23;  de- 
scription of  the  casual  cow-pox  of,  MB; 
mistakes  into  which  they  fall  from  con- 
tracting spurious  pocks,  20. 

Mold,  district  of,  statistics  of  vaccination 
in  the,  289. 

Moravia,  decline  of  small-pox  in,  since  the 
introduction  of  vaccination,  280. 

National  statistics  of  small-pox,  showing 
the  protective  power  of  vaccination,  279. 

National  Vaccine  Establishment,  success- 
ful practice  of  vaccination  atits  stations, 
180  «.,  181;  its  rule  as  to  the  perform- 


INDEX. 


381 


ance  of  vaccination,  189 ;  demands  on 
it  for  lymph-supply  by  practitioners  in 
England,  146  «.,  151  «.;  its  lymph  is 
chiefly  of  Jenner's  stock,  202;  compari- 
son  of  this  lymph  with  more  recent 
lymphs,  207;  appointment  of  teaching 
stations  in  connection  with  the  Estab- 
lishment, 185. 

Navy,  vaccination  in  the,  271 ;  small-pox 
in  the,  257,  266,  274,  291. 

Neath  Union,  deaths  from  small-pox  in 
the,  292  a. 

Newport  Union,  deaths  from  small-pox  in 
the,  292  n. 

Northampton,  scandalous  neglect  of  vac- 
cination in,  and  fatal  epidemics  of  small- 
pox, 281  n.,  292  n. 

Northampton  Union,  deaths  from  small- 
pox in  the,  281  n. 

Ortmiii,  small-pox  on  board  the,  268. 

Urination  of  the  human  subject,  45;  Sac- 
en's  experiments,  45;  Marson'sand  Cee- 
ly's,  47 ;  of  cows,  etc.,  51. 

Paget,  Professor,  his  opinion  that  skin 
diseases  and  syphilis  are  not  communi- 
cable by  vaccination,  337,  339,  342. 

Paine,  Dr.,  his  observations  at  Cardiff, 
showing  the  protective  power  of  vaccin- 
ation, 264. 

Papulo-vesicular  eruptions  attendant  on 
vaccination,  84;  more  frequently  seen 
when  cow-lymph  is  used,  103. 

Passy  lymph,  use  of,  205. 

Pearse,  Dr.,  his  table  of  results  of  tube- 
lymph  compared  with  vaccination  from 
the  arm,  170. 

Photoshootur,  the  small-pox  of  camels,  54. 

Pocks  in  animals  which  have  been  consid- 
ered analogous  to  cow-pox  and  horse- 
pox,  44 ;  the  sheep-pox,  44 ;  the  camel- 
pox,  54. 

Points  used  for  preserving  lymph,  161. 

Pontypool  Union,  deaths  from  small-pox 
in  the,  292  w. 

Pontypridd  Union,  deaths  from  small-pox 
in  the,  292  ft. 

Portsmouth,  serious  consequences  of  neg- 
lect of  vaccination  in,  291. 

Private  vaccination,  hints  concerning  ar- 
rangements for,  155. 

Privy  Council,  teaching  stations  appointed 
in  connection  with  National  Vaccine 
Establishment,  185. 

Protection  from  small-pox  afforded  by  vac- 
cination, 220,231. 

Provincial  Medical  Association,  cases  of 
recurrent  small-pox  collected  by  the, 
227. 

Puncture,  methods  of  vaccination  by,  126. 

Recurrent  small-pox  (see  Small-pox). 

Registrar-General's  facts,  showing  the  de- 
crease in  small-pox  from  the  increased 
observance  of  vaccination,  since  compul- 
sory act.  212 

Retro-vaccination  of  cows,  25,  30. 

Retro-vaccine  lymph,  vaccination  with, 
112. 

Reraccination,  phenomena  and  course  of, 
113:  purposes  lor  which  it  is  necessary, 
299 ;  carelessness  in  primary  vaccination 


not  to  be  excused  on  the  ground  that  re- 
vaccination  will  make  good  its  defects, 
300 ;  age  at  which  it  should  be  performed, 
301 ;  circumstances  under  which  it  is 
called  for  in  childhood,  301 ;  it  should  be 
performed  on  all  persons  after  puberty, 
303;  requires  the  same  care  and  pains 
in  its  performance  as  primary  vaccina- 
tion, 306 ;  the  performance  of,  should  not 
be  left  to  periods  when  small-pox  is 
epidemic,  308:  the  local  results  produced 
by  it  in  individuals  give  no  indication 
as  to  the  person's  liability  to  small-pox, 
310;  table  representing  the  results  of,  in 
the  Wirtemberg  and  British  armies,  311. 

Rieumes,  outbreak  of  the  horse-pox  at,  38. 

Roseola,  vaccine,  83. 

Royal  Military  Asylum,  illustration  of  the 
protection  of  vaccination  from,  275. 

Sacco,  his  observations  on  cow-pox,  22  n., 

23;  his  ovinations  of  human  subjects,  45; 

his  great  services   in  the  diffusion   of 

vaccination,    49    n. ;     his    experiments 

showing  that  lymph  did  not  degenerate, 

285. 
St.  Giles's,  London,  small-pox  routed  out 

of,  324. 
Sanitary  Act,  1866,  prohibits  exposure  of 

persons  affected  with  small-pox,  317  n. 
Scarification,   modes  of    vaccination    by, 

129;  probably  the  most  effective  way  of 

vaccinating,  134. 
Scarlatina,  effects  of  incubation  of,  on  the 

course  of  vaccination,  86. 
Scotland,    mortality    from    small-pox    in 

different  kinds  of  districts  in,  261. 
Second  small-pox,  224,  proportion  of  deaths 

to  coses  of,  296  ft. 
Sheep,  vaccination  of,  51 ;  variolation  of, 

53. 
Sheep-pox,  short  description  of,  44.    (See 

OVINATION.) 

Sheffield,  deaths  from  small-pox  in,  319; 
gross  neglect  of  vaccination  in,  319  n. 

Shrewsburv  Union,  deaths  from  small-pox 
in  the,  292  n. 

Silesia,  decline  of  small-pox  in,  since  the 
introduction  of  vaccination,  280. 

Simon,  M.,  his  preface  to  "papers  rela- 
ting to  the  history  and  practice  of  vaccin- 
ation," referred  to  and  quoted  pastim. 

Simonds,  Professor,  his  experiments  in 
vaccination  of  sheep,  51. 

Skin  diseases  in  children,  not  attributable 
to  vaccination,  334. 

Small-pox,  Jenner's  hypothesis  of  its 
origin  in  the  horse,  56;  its  relation  to 
cow-pox  and  horse-pox,  56;  fatality  of 
the  natural  small-pox  in  man,  211 ;  pro- 
portion of  deaths  to  attacks,  214.  23S; 
the  ravages  it  made  before  the  discovery 
of  vaccination,  211 ;  its  characters  when 
uncontrolled  by  vaccination  still  the 
same,  213;  introduction  of  variolous  in- 
oculation, and  its  results,  216;  small- 
pox may  recur  after  natural  small-|«ix, 
224;  orafter  inoculated  small-pox,  225; 
frequency  or  infrequency  of  recurrent 
small-pox  227;  the  protection  against 
small-pox  afforded  by  vaccination,  221 ; 
medical  testimony  respecting  it,  239; 
modes  in  which  the  power  of  vaccination 


382 


INDEX. 


over  small-pox  is  manifested,  233;  1st, 
by  conferring  on  the  majority  of  the 
vaccinated  complete  immunity  from, 
233:  2d,  by  modifying  its  course  or 
diminishing  its  danger,  236:  modifica- 
tions exhibited  by  post-vaccinal  small- 
pox, 231,  231,  236;  influence  of  the 
quality  of  vaccination  on  these  modifica- 
tions, and  on  the  protective  power  of 
vaccination  generally,  240;  influenoe  of 
age,  250;  of  personal,  hereditary,  or 
family  tendency,  254 ;  of  climatic  change, 
257;  of  amount  of  exposure,  259;  of  epi- 
demic intensity,  269 ;  the  mortality  from 
small-pox  natural,  secondary,  and  post- 
vaccinal, in  Small-pox  Hospital,  an- 
alyzed, 242:  mortality  in  the  British 
army  and  navy,  253,  257,  271;  in  Nor- 
wich, analyzed,  262;  in  epidemic  at 
Chelsea,  analyzed,  268 ;  in  Cardiff",  an- 
alyzed, 264;  in  particular  ships  in  the 
navy,  analyzed,  266  mortality  in  India 
and  tropical  climates,  276 ;  rate  of  mor- 
tality affected  by  epidemic  intensity, 
238  n.,  270;  decline  of  small-pox  mor- 
tality in  correspondence  with  the  adop- 
tion of  vaccination,  279;  summary  of 
annual  deaths  by,  in  England  and  Wales, 
282;  annual  rate  of  deaths  per  million 
of  the  population,  283 ;  evidence  that  the 
present  small-pox  mortality  in  England 
is  due  to  neglect  of  vaccination,  and  to 
its  inefficient  performance,  286;  from 
analysis  of  death  returns,  286 ;  from  the 
results  of  special  inquiries,  287;  small- 
pox mortality  in  particular  places,  where 
there  had  been  very  gross  neglect  of 
vaccination,  281  n.,  290, 318;  of  stamping- 
out  local  outbreaks  of,  314;  universal 
vaccination  would  render  the  dangers 
of  small-pox  inconsiderable,  314;  dan- 
gers arising  now  from  neglect  of  that 
practice,  314 ;  steps  that  should  be  taken 
to  prevent  small-pox  spreading,  315; 
importance  of  isolating  the  early  cases, 
316 ;  steps  to  arrest  it  when  it  has  begun 
to  spread,  318";  steps  necessary  when  it 
is  extensively  diffused,  322;  measures 
of  thorough  disinfection  steadily  pur- 
sued, indispensable,  317,  323;  responsi- 
bility of  local  authorities  for  preventing 
the  spread  of,  327. 

Small-pox  Hospital,  observations  made  at, 
on  small-pox  natural  and  post-vaccinal, 
214,  237,  242,  252,  270;  on  second  small- 
pox, 231,  212;  experience  of  the,  in  re- 
vaccination,  308. 

Small-pox  reported  as  "after  vaccination," 
frequent  mistakes  about  this,  240 ;  and 
frequent  erroneous  entries  to  this  effect 
in  death-registers,  122  ».,  241  ».,  251  n. 

Soldiers  (see  Army). 

Sperino  disbelieves  the  vaccinal  origin  of 
the  syphilitic  endemic  at  Rivalta,  370; 
his  experiments  on  vaccinal  syphilis, 
348,  371. 

Spring,  cow-pox  manifests  itself  chiefly  in 
the,  24. 

8purions  pocks  in  the  cow,  18. 

Spurious  vaccination,  91  n.\  causes  of,  90. 

Steele's  comparative  experiments  of  lymph 
supplied  by  Jenner,  with  other  lymph, 
202. 


Storage  of  lymph,  158 ;  various  modes  of, 
160;  points,  161;  glasses  and  tubes,  162; 
the  best  mode  of,  considered,  168. 

Stored  lymph,  vaccinating  with,  125,  131 ; 
standard  of  success  when  this  is  used, 
181 ;  failures  of,  in  unskillful  hands, 
191 ;  unnecessary  and  injurious  extent 
to  which  it  is  used  in  England,  156. 

Supernumerary  vesicles,  96. 

Sweden,  decline  of  small-pox  in,  since  the 
introduction  of  vaccination,  280. 

Syphilis,  allegation  that  it  may  be  invac- 
cinated,  337  ;  not  supported  by  general 
professional  experience,  337 ;  may  be 
produced  of  course  by  accidental  inser- 
tion of  its  own  virus,  346 ;  question  of 
accidental  inoculation  of,  by  the  blood, 
353 ;  errors  of  diagnosis  respecting,  357  ; 
frequent  difficulty  of  ascertaining  its 
real  origin,  358;  cases  of  alleged  pro- 
duction of,  by  vaccination,  360;  prac- 
tical and  common-sense  view  of  the  ob- 
jection to  vaccination,  founded  on  such 
cases,  374. 

Syphilitic  endemics,  of  unascertained  ori- 
gin, 368. 

Tanner's  experiments  with  lymph  from 
the  horse,  34. 

Thiele,  Dr.,  his  successful  attempts  to  in- 
oculate the  cow  with  variolous  virus, 
59. 

Tomkins,  Mr.,  on  syphilis  not  being  at- 
tributable to  vaccination,  3K>. 

Trousseau,  M.,  his  case  of  alleged  vaccinal 
syphilis,  366. 

Tubes  used  for  collecting  and  preserving 
lymph,  162 ;  wood-cuts  of,  165,  166,  168 ; 
comparison  of  this  method  of  storage 
with  other  methods,  186. 

Vaccinal  Syphilis,  alleged  cases  of,  360. 

Vaccination  (see  also  Cow-pox)  of  cows, 
25 ;  of  horses,  40 ;  of  sheep,  51 ;  of  other 
animals,  54;  of  the  human  subject,  80; 
phenomena  and  course  of,  in  the  human 
subject,  80 ;  usual  course,  81 :  abnormal 
course,  85 ;  retarded,  85 ;  accelerated, 
89 ;  spurious,  and  its  causes,  89 ;  effects 
of  mechanical  irritation  on  the  course 
of,  92 ;  degeneration  of  the  vaccine  vesi- 
cle, erysipelas,  etc,  93:  effects  of  climate 
on  the  course  of,  94 ;  supernumerary  vesi- 
cles, 96;  effects  of  reinsertion  of  vaccine 
lymph  within  five  days  of  a  successful 
insertion  (Bryce's  test),  98:  its  history, 
99;  vaccination  with  primary  cow- 
lymph,  101 ;  local  and  general  phenome- 
na, 102;  progress  of  humanization  of 
lymph,  104 ;  varieties  in  amount  of  con- 
stitutional disturbance,  104 ;  vaccination 
with  variola-vaccine  lymph,  107 ;  with 
secondary  or  inoculated  cow-lymph,  109 ; 
animal  vaccination,  109 ;  with  retro- 
vaccine  lymph,  112;  phenomena  and 
course  of  revaccination,  113;  treatment 
of,  114;  origin  of  the  term,  115. 

Vaccination,  insusceptibility  of,  196. 

Vaccination,  objections  to,  and  alleged 
dangers  of,  328;  the  allegation  that  it 
has  produced  new  diseases,  328,  and  led 
to  increase  of  mortality,  329 ;  allegation 


INDEX. 


383 


that  cutaneous  and  glandular  diseases 
may  be  invaccinated,  334;  allegation 
that  syphilis  may  be  invaccinated,  337 ; 
harmlessness  of,  is  dependent  on  due 
care  being  used,  346;  practice  of,  in 
France  and  Italy,  348,  350  n. 

Vaccination,  performance  of,  things  to  be 
attended  to  in  vaccinating,  115;  state  of 
the  individual  to  be  vaccinated,  115; 
health  and  age  of  the  patient,  115,  117; 
circumstances  which  call  for  the  imme- 
diate performance  of,  119;  selection  of 
the  lymph  to  be  used  in,  123;  collection 
of  the  lymph,  124 ;  whether  and  under 
what  circumstances  to  be  done,  from  the 
arm,  or  with  stored  lymph,  125:  various 
methods  of  inserting  the  lymph,  126 ;  its 
course  to  be  watched,  and  the  results 
closely  inspected,  134;  performance  of, 
from  the  natural  or  casual  disease  in  the 
cow,  1%;  arrangements  for  the  opera- 
tion of,  and  the  maintenance  of  lymph- 
supply,  140;  advantage  of  arm-to-arm 
vaccination,  140;  methods  and  suitable 
arrangements  requisite  for,  140;  selec- 
tion of  lymph  necessary,  141 ;  of  skill 
and  success  in  the,  179 ;  necessity  for  a 
standard  of  comparison  as  to  what  is 
success,  179;  Marson's  standard,  180; 
standard  when  stored  lymph  is  used, 
181 ;  skill  of  the  operator  the  most  im- 
portant of  all  the  conditions  for  success, 
182;  advantages  of  appointing  professed 
vaccinators,  186;  consequences  resulting 
from  want  of  proper  instruction  in,  187 ; 
official  inquiry  respecting,  188;  repeated 
failures  of,  from  want  of  skill,  190. 

Vaccination,  protection  a  Horded  by, against 
small-pox,  221 ;  summary  of  its  advan- 
tages, 29.">  (see  Small-pox);  its  univer- 
sal performance  would  render  the  dan- 
gers of  small-pox  quite  inconsiderable, 
295,314. 

Vaccination,  public,  in  large  towns,  147; 
in  smaller  towns,  152;  in  rural  districts, 
153;  illustrations  of  the  disadvantages 
which  have  frequently  attended  the  ar- 
rangements for,  heretofore  in  force,  156. 

Vaccination,  quality  of,  extreme  import- 
ance of  attention  to  this,  187,  19.">,  241 ; 
illustrated  by  observations  at  Small-pox 
Hospital,  242;  by  inquiries  of  Epidem- 
iological Society,  247;  by  observations 
of  Seaton  and  Buchanan.* 247. 

Vaccination  in  England,  results  as  regards 
neglect  of,  286  ;  as  regards  its  imperfect 
performance,  188;  as  regards  the  ar- 
rangements existing,  156. 

Vaccinators,  the  skill  of,  the  most  im- 


portant of  all  the  conditions  for  success- 
ful vaccination,  182;  necessity  for  their 
special  instruction,  182;  advantages 
which  would  attend  the  appointment  of 
professed  "vaccinators,"  186. 

Vaccine  crusts,  use  of  the,  174. 

Vaccine  lichen,  83. 

Vaccine  lymph  (see  Lymfb). 

Vaccine  roseola,  83. 

Vaccine  vesicle,  degeneration  of  the,  93. 

Vaccinia,  or  cow-pox,  never  met  with  in 
the  human  subject  but  as  the  result  of 
inoculation,  9.  (See  Cow-pox  Vaccina- 
tion.) 

Vaccino-syphilitic  inoculation,  alleged 
cases  of,  355. 

Variola,  human,  relation  of  cow-pox  and 
horse-pox  to,  56. 

Variola  ovina  (see  Sheep-pox). 

Variola  vaccine  lymph,  vaccination  with, 
62,  64,  107. 

Variolse  equinae,  a  name  applied  to  the 
horse-pox,  37. 

Variola?  vaccinae,  name  given  by  Jenner 
to  cow-pox,  9. 

Variolation,  vaccine  disease  may  be  in- 
duced in  cows  by,  59;  phenomena  of, 
successful  in  cows,  63;  attempted  vario- 
lation of  horses,  41;  of  sheep,  53;  of 
other  animals,  54. 

Variolous  affection,  cattle  not  shown  to 
be  subject  to  any  other  than  cow-pox,  74. 

Variolous  effluvia,  case  of  infection  of  cat- 
tle by,  62. 

Variolous  inoculation,  introduction  of.  216; 
not  wholly  void  of  risk,  bnt  not  so  dan- 
gerous as  the  natural  small-pox,  297. 

Vesicle,  vaccine,  structure  of  the,  17,  81. 

Vesicles,  supernumerary,  96. 

Vesicles  produced  by  Jenner's  lymph,  201 ; 

Produced  by  the  lymph  of  the  Academie 
e  Medecine,  206;  produced  by  various 
lymphs,  207. 
Vleminkx's  observations  on  revaccination 
in  Belgium,  312. 

West,  Dr.,  his  opinion  that  neither  cuta- 
neous nor  syphilitic  diseases  are  commu- 
nicated by  vaccination,  336. 

Westphalia,  decline  of  small-pox  in,  since 
the  introduction  of  vaccination,  280. 

White  pock,  19. 

Whitehaven  Union,  deaths  from  small-pox 
in  the,  292  n. 

Woodville,  Dr.,  mistakes  into  which  he 
fell  an  to  the  characters  of  the  cow-pox, 
79  n. 

Yellow  pock,  19. 


757 


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